Case for Diagnosis
Bilateral Annular Plaques on the Hands and Forearms
Placas anulares bilaterales en manos y antebrazos
E. Rozas-Muñoz
, J.F. Mir-Bonafé, E. Serra-Baldrich
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Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Rozas-Muñoz, J.F. Mir-Bonafé, E. Serra-Baldrich" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Rozas-Muñoz" "email" => array:1 [ 0 => "docrozas@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.F." "apellidos" => "Mir-Bonafé" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Serra-Baldrich" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placas anulares bilaterales en manos y antebrazos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1081 "Ancho" => 1658 "Tamanyo" => 272209 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 56-year-old man with no relevant past history presented with mildly pruritic lesions on the dorsal aspect of both forearms that had first appeared 8 months earlier. The patient reported no history of applying products to the affected area and mentioned no possible triggers.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed large erythematous plaques with slightly raised borders and a central depression affecting the dorsal aspect of both forearms and hands. The lesions had an annular morphology and, interestingly, spared the area covered by the watch on the left wrist (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Epicutaneous tests from the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) and standard photopatch tests were negative.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Histologic examination of a punch biopsy specimen taken from the border of one of the plaques revealed an epidermis without significant alterations. A superficial granulomatous and perivascular infiltrate composed of mononuclear cells and multinucleated giant cells was observed in the upper and mid dermis. The cytoplasm of these cells contained numerous fragmented elastic fibers rendered more visible by Verhoeff-Van Gieson staining. Neither collagen degeneration nor the presence of mucin were observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Annular elastolytic giant cell granuloma (actinic granuloma).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment was started with medium-strength topical corticosteroids and sun protection. Partial improvement of the lesions was observed after 3 months of application.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Annular elastolytic giant cell granuloma (AEGCG), also known as actinic granuloma or O’Brien granuloma, is a rare granulomatous disease characterized by the presence of multinucleated giant cells with phagocytosis of anomalous elastic fibers, a process known as elastophagocytosis. AEGCG mainly affects women aged 50 to 70 years with a light skin phototype and signs of chronic actinic damage. The lesions usually begin as erythematous papules that later evolve into annular plaques with raised borders and a minimal atrophic center. The most common sites are sun-exposed areas such as the face, upper chest, and legs.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The pathogenesis of this entity is unknown, although the possibility of an autoimmune reaction directed against elastic fibers, determining a granulomatous inflammatory response with the formation of granulomas, has been postulated.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> AEGCG has been described in association with various processes, including diabetes mellitus, medication use, hypothyroidism, thyroiditis, lymphomas, polymyalgia rheumatica, and temporal arteritis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">At present, it is not known whether there is a relationship between AEGCG and these processes.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Histopathology shows 3 well-defined zones that reflect this possible pathogenesis. A peripheral zone, outside the borders of the plaques, is characterized by a papillary dermis with actinic elastosis, without the presence of multinucleated giant cells or granulomas. This zone, in which the lesion progresses, contains antigenic elastic fibers that have not yet induced an inflammatory reaction. In an intermediate or active zone—corresponding clinically to the edge of the lesions—fragmented elastic fibers, elastophagocytosis phenomena, and granuloma formation are observed. Finally, a central zone, characterized by the absence of elastic fibers and few inflammatory cells, is the residual postinflammatory zone.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The main differential diagnosis is granuloma annulare (GA) at sun-exposed sites. In fact, since AEGCG was first described, there has been some debate about whether it is a distinct entity or a variant of GA with elastophagocytosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Although these two processes can be clinically identical, histologic studies support the idea that they are separate entities. In AEGCG, the granulomatous reaction is found mainly in the upper dermis and no mucin is observed, whereas in GA, granulomas are distributed throughout the upper and mid dermis, forming a palisade around an area characterized by degenerated collagen and the presence of mucin.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although spontaneous remission has been reported in some cases, AEGCG tends to be chronic and recurring. Multiple treatment options have been described, including sun protection; topical, systemic, or intralesional corticosteroids; chloroquine; dapsone; methotrexate; anti–tumor necrosis factor (TNF) monoclonal antibodies; and low-dose oral retinoids. These treatments have produced variable results.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6–8</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rozas-Muñoz E, Mir-Bonafé JF, Serra-Baldrich E. Placas anulares bilaterales en manos y antebrazos. Actas Dermosifiliogr. 2018;109:263–264.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1081 "Ancho" => 1658 "Tamanyo" => 272209 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1570 "Ancho" => 1625 "Tamanyo" => 1024193 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>4. B, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>40. C, Verhoeff-Van Gieson, original magnification ×<span class="elsevierStyleHsp" style=""></span>40. D, Alcian blue, original magnification ×<span class="elsevierStyleHsp" style=""></span>20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Granuloma actínico. Estudio clínico e histológico de cinco casos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Bassas-Vila" 1 => "P. Umbert" 2 => "M. Iglesias" 3 => "L. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 8 | 7 | 15 |
| 2024 Octubre | 77 | 50 | 127 |
| 2024 Septiembre | 67 | 26 | 93 |
| 2024 Agosto | 106 | 51 | 157 |
| 2024 Julio | 90 | 44 | 134 |
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| 2024 Marzo | 75 | 25 | 100 |
| 2024 Febrero | 64 | 33 | 97 |
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| 2023 Noviembre | 98 | 21 | 119 |
| 2023 Octubre | 61 | 20 | 81 |
| 2023 Septiembre | 71 | 34 | 105 |
| 2023 Agosto | 55 | 12 | 67 |
| 2023 Julio | 40 | 33 | 73 |
| 2023 Junio | 50 | 27 | 77 |
| 2023 Mayo | 69 | 20 | 89 |
| 2023 Abril | 58 | 19 | 77 |
| 2023 Marzo | 68 | 28 | 96 |
| 2023 Febrero | 70 | 32 | 102 |
| 2023 Enero | 38 | 30 | 68 |
| 2022 Diciembre | 72 | 36 | 108 |
| 2022 Noviembre | 25 | 33 | 58 |
| 2022 Octubre | 32 | 21 | 53 |
| 2022 Septiembre | 26 | 40 | 66 |
| 2022 Agosto | 30 | 30 | 60 |
| 2022 Julio | 63 | 34 | 97 |
| 2022 Junio | 31 | 26 | 57 |
| 2022 Mayo | 40 | 47 | 87 |
| 2022 Abril | 60 | 44 | 104 |
| 2022 Marzo | 55 | 60 | 115 |
| 2022 Febrero | 35 | 40 | 75 |
| 2022 Enero | 41 | 57 | 98 |
| 2021 Diciembre | 37 | 52 | 89 |
| 2021 Noviembre | 65 | 55 | 120 |
| 2021 Octubre | 52 | 68 | 120 |
| 2021 Septiembre | 38 | 45 | 83 |
| 2021 Agosto | 51 | 48 | 99 |
| 2021 Julio | 42 | 38 | 80 |
| 2021 Junio | 39 | 44 | 83 |
| 2021 Mayo | 41 | 68 | 109 |
| 2021 Abril | 85 | 137 | 222 |
| 2021 Marzo | 65 | 49 | 114 |
| 2021 Febrero | 86 | 50 | 136 |
| 2021 Enero | 48 | 50 | 98 |
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| 2020 Noviembre | 40 | 55 | 95 |
| 2020 Octubre | 16 | 20 | 36 |
| 2020 Septiembre | 23 | 16 | 39 |
| 2020 Agosto | 38 | 30 | 68 |
| 2020 Julio | 26 | 20 | 46 |
| 2020 Junio | 34 | 37 | 71 |
| 2020 Mayo | 18 | 14 | 32 |
| 2020 Abril | 19 | 14 | 33 |
| 2020 Marzo | 15 | 10 | 25 |
| 2020 Febrero | 3 | 1 | 4 |
| 2020 Enero | 2 | 0 | 2 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 10 | 0 | 10 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 6 | 0 | 6 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Abril | 1 | 0 | 1 |
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