Evolution of granuloma annulare to mid‐dermal elastolysis: report of a case and review of the literature

Abstract

A 55-year-old healthy Caucasian female, on no medication, was seen by a dermatologist because of a patchy, slightly indurated and violaceous eruption involving her neck and trunk. The clinical impression was of granuloma annulare (GA). Over a period of several months the violaceous lesions became atrophic with loss of colour and eventual wrinkling of lesional skin. Sequential skin biopsies were obtained, which revealed a spectrum of changes. Those from early violaceous lesional zones displayed perivascular lymphocytic infiltrates and interstitial granulomatous inflammation, characteristic of interstitial GA. Samples from atrophic lesional areas appeared normal on routine sections but an Orcein-Giemsa (OG) stain, prompted by the clinical history of atrophy, revealed absence of elastic fibers in the mid-reticular dermis. The combined clinicopathologic findings pointed to development of mid-dermal elastolysis (MDE) at involutional sites of GA. Owing to consideration of a cutaneous T-cell lymphoma in the differential diagnosis, genotyping in search of T-cell monoclonality was performed and yielded a negative result. Our case supports the existing but scant evidence in the literature that the rare, enigmatic condition termed MDE is an end-result of inflammatory destruction of dermal elastic fibers. GA is one form of dermatitis capable of culminating in this entity, but others have also been implicated.

Dermal elastolysis in the setting of combination immunotherapy

“…The etiology of many disorders of elastic tissue remains unknown; however, post‐inflammatory elastolysis has previously been described and reported to be induced by multiple drugs and diseases including minocycline, penicillamine, penicillin, isoniazid, granuloma annulare, multiple myeloma, amyloidosis, and solar exposure . While post‐inflammatory elastolysis and cutis laxa are generally confined to the skin, many cases of both secondary anetoderma and acquired cutis laxa have progressed to involve organs outside of the skin, including the gastrointestinal tract, the cardiovascular system, and the pulmonary system .…”

“…When the loss of elastic tissue is confined to the papillary dermis, differential diagnosis includes pseudoxanthoma elasticum-like papillary dermal elastolysis (PXE-PDE), white fibrous papulosis of the neck, late-onset focal dermal elastolysis, and upper dermal elastolysis 1. The etiology of many disorders of elastic tissue remains unknown; however, post-inflammatory elastolysis has previously been described and reported to be induced by multiple drugs and diseases including minocycline, penicillamine, penicillin, isoniazid, granuloma annulare, multiple myeloma, amyloidosis, and solar exposure 3,4. While postinflammatory elastolysis and cutis laxa are generally confined to the skin, many cases of both secondary anetoderma and acquiredF I G U R E 1 Skin-colored, atrophic, wrinkled papules seen in patient 1 following an erythematous eruption while on nivolumab and cabiralizumab therapy F I G U R E 2 Hematoxylin and eosin stain at 200× from involved skin of patient 1 showing an unremarkable epidermis with mild superficial dermal elastosis (A).…”

Mid-dermal elastolysis: A female-centric disease; case report and updated review of the literature

“…Finally, there was one report of two male patients with Type III MDE (Meyer et al, 2012). The remainder of the publications were novel cases of Type I and II MDE (Cohen and Tschen, 2013, Cota et al, 2014, Lai et al, 2014, Martinez-Escala et al, 2012) or Type III MDE (Cutillas et al, 2010, Gambichler and Lubbe, 2012, Posada et al, 2013). …”

Annular Erythematous Plaques With Central Hypopigmentation on Sun-Exposed Skin

“…Annular elastolytic granuloma clinically is similar to granuloma annulare (GA), with both presenting as annular plaques surrounded by an elevated border. 1 Although AEG clinically is distinct with hypopigmented atrophied plaque centers, 2 a biopsy is required to confirm the lack of elastic tissue in zones of atrophy and the presence of multinucleated histiocytes. 1,3 Lesions most commonly are seen clinically on sun-exposed areas in middle-aged White women; however, they rarely have been seen on frequently covered skin.…”

“…1 Although AEG clinically is distinct with hypopigmented atrophied plaque centers, 2 a biopsy is required to confirm the lack of elastic tissue in zones of atrophy and the presence of multinucleated histiocytes. 1,3 Lesions most commonly are seen clinically on sun-exposed areas in middle-aged White women; however, they rarely have been seen on frequently covered skin. 4 Our case illustrates the striking photodistribution of AEG, especially on the posterior neck area.…”