Clinical Challenge: A Brown Plaque on the Nose - MPR

Clinical Challenge: A Brown Plaque on the Nose

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A 45-year-old woman presents complaining of an asymptomatic brown plaque on her face that has been present for four months.

Granuloma faciale (GF) usually presents as a singular, smooth, asymptomatic, reddish-brown to purplish papule or plaque with marked follicular openings.GF is usually asymptomatic, but symptoms such as itching and burning have been reported, albeit rarely. The incidence in females is...

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Granuloma faciale (GF) usually presents as a singular, smooth, asymptomatic, reddish-brown to purplish papule or plaque with marked follicular openings.

GF is usually asymptomatic, but symptoms such as itching and burning have been reported, albeit rarely. The incidence in females is slighter lower than in males. 

On histology, a prominent grenz zone can be seen, along with the presence of a mixed inflammatory infiltrate consisting of neutrophils, plasma cells, lymphocytes and eosinophils. 

Diagnosis & Treatment

Key diagnostic features of granuloma faciale are the lesion’s location and the reddish-brown to violaceous color. The lesion can mimic other disease states, so if the diagnosis is uncertain a biopsy may be taken. 

On histology, a prominent grenz zone and a dense mixed inflammatory infiltrate are characteristic features. 

The first line of treatment for granuloma faciale is typically intralesional triamcinolone. If the first line of treatment fails to show the desired results, anecdotal success has been reported with other interventions. These include oral dapsone, oral clofazimine, topical photochemotherapy and topical calcineurin.

More invasive techniques have been described, such as surgical excision, cryosurgery, and electrosurgery. 

Prior to treatment, the patient should be educated on GF’s resistance to therapy, along with the risk of scarring. There is risk of recurrence with any treatment modality.      

Other answer choices

Granuloma inguinale, also known as donovanosis, is a sexually transmitted infection that is caused by the bacteria Klebsiella granulomatis. 

The initial lesion appears as a single nodule that ruptures after an incubation period that usually lasts between two to three weeks. The developed lesion is typically painless, foul smelling and highly vascular, hence the characteristic “beefy” appearance of the lesion.  

Granuloma gluteale infantum (GCI) is a condition caused by chronic, severe contact dermatitis, specifically in children with chronic diarrhea. GCI typically presents as ovoid, erythematous to purplish nodules or plaques.

For treatment, any suspected irritants should be avoided, and barrier creams and topical antifungals may be beneficial. Resolution should occur after contact with the causative factor ceases and may take several months.

Granular cell tumors (GCTs) are fairly rare tumors that are typically benign and seemingly develop from neural origins. They usually occur in adults, and have a predilection for females, with approximately 75% of the cases occurring in women.

The majority of GCTs occur on the head – 70% – with 30% of those lesions found on the tongue. After the head, the breast and proximal extremities are the most common locations of granular cell tumors.

GCT typically presents as a 0.5 cm to 3.0 cm skin-colored to brownish-red lesion with an occasionally ulcerated surface. The lesion is normally asymptomatic and slow growing, but the recommended course of treatment is complete surgical excision of the lesion.

Stephen Curtis, BS, is a graduate of Texas A&M University. 

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine also in Houston.

References

  1. Goldsmith L, Katz SI, Gilchrest BA, Paller AS et al. Fitzpatrick’s Dermatology in General Medicine. 2012; New York: McGraw-Hill Medical. Print. 
  2. Bolognia J, Jorizzo JL, Schaffer JV. Dermatology. 2012; Philadelphia: Elsevier Saunders. Print. 
  3. Abbas O, Mahalingam M. “The grenz zone.” Am J Dermatopathol. 2013; 35(1):83-91.