|Year : 2020 | Volume
| Issue : 1 | Page : 54-56
Palisaded neutrophilic granulomatous dermatitis: Case report and review of literature
Bashair Ali Alzahrani1, Anas Muwaffaq Tayeb1, Johara Abdulkarim2, Ruba Bahadur2, Abdullah Almontashiri1, Khalid Al Hawsawi1
1 Department of Dermatology, King Abdul Aziz Hospital, Makkah, Saudi Arabia
2 College of Medicine, Umm AlQura University, Makkah, Saudi Arabia
|Date of Submission||20-Sep-2019|
|Date of Acceptance||26-Nov-2019|
|Date of Web Publication||27-Mar-2020|
Dr. Khalid Al Hawsawi
House #4148, Al-Takassosi District, Branch #6134, Unit #1, Makkah 24323
Source of Support: None, Conflict of Interest: None
Palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare inflammatory dermatosis. We report a 45-year-old female with a 2-year history of asymptomatic persistent skin lesions. The patient had rheumatoid arthritis well controlled with abatacept, methotrexate, and hydroxychloroquine. Multiple nonscaly umbilicated papules with crusted center were scattered on her abdomen, chest wall, and back. Biopsy showed pandermal infiltrate of neutrophils and areas of basophilic degenerated collagen surrounded by palisades of histiocytes, neutrophils deep in the dermis, and subcutaneous fat. A diagnosis of PNGD was made. The patient was treated with betamethasone dipropionate (0.05%) ointment and oral colchicine with good improvement.
Keywords: Interstitial granulomatous dermatitis with arthritis, palisaded neutrophilic granulomatous dermatosis, rheumatoid papules
|How to cite this article:|
Alzahrani BA, Tayeb AM, Abdulkarim J, Bahadur R, Almontashiri A, Al Hawsawi K. Palisaded neutrophilic granulomatous dermatitis: Case report and review of literature. J Dermatol Dermatol Surg 2020;24:54-6
|How to cite this URL:|
Alzahrani BA, Tayeb AM, Abdulkarim J, Bahadur R, Almontashiri A, Al Hawsawi K. Palisaded neutrophilic granulomatous dermatitis: Case report and review of literature. J Dermatol Dermatol Surg [serial online] 2020 [cited 2020 Aug 14];24:54-6. Available from: http://www.jddsjournal.org/text.asp?2020/24/1/54/281428
| Introduction|| |
Palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare inflammatory dermatosis. Synonyms include interstitial granulomatous dermatitis (IGD) with arthritis, rheumatoid papules, rheumatoid granuloma, and superficial ulcerating rheumatoid necrobiosis.
PNGD is typically associated with underlying disease, including autoimmune connective tissue disease, lymphoproliferative disorders, infections, and drugs including anti-tumor necrosis factor (TNF) agents and allopurinol. PNGD has a wide range of clinical features. It presents as tender or asymptomatic multiple umbilicated papules with central perforation or crusting or as erythematous to violaceous papules, plaques or nodules, or annular plaques., PNGD appears most commonly on the extensor surfaces, especially elbows and fingers. It affects upper extremities in 51% of the cases; lower extremities in 27% of the cases; and trunk, head, and neck in 21% of the cases. Histologically, early lesions have neutrophilic infiltrates and leukocytoclastic vasculitis, whereas fully developed lesions consist of palisaded granulomas. We present a patient with PNGD in the setting of rheumatoid arthritis (RA) with good response to (but not clearing with) betamethasone dipropionate 0.5% ointment and oral colchicine treatment.
| Case Report|| |
A 45-year-old female presented with 2-year history of asymptomatic persistent skin lesions that were increasing in number over time. She had RA that was well controlled by abatacept, methotrexate, and hydroxychloroquine. The lesions were multiple nonscaly umbilicated papules with crusted centers scattered on her abdomen, chest wall, and back [Figure 1]. Hairs, nails, and mucus membranes were all normal. Skin biopsy showed a pandermal cellular infiltrate composed of neutrophils, lymphocytes, eosinophils, and areas of basophilic degenerated collagen deep in the dermis and subcutaneous fat surrounded by palisades of histiocytes [Figure 2]. A diagnosis of PNGD was made. The patient was treated with betamethasone dipropionate (0.05%) ointment and oral colchicine 0.5 mg tablet twice daily with good improvement, but new lesions continued to appear.
|Figure 1: Multiple nonscaly erythematous to skin colored papules with central crust or perforation on the abdominal wall|
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|Figure 2: (a) Epidermis shows crust in the stratum corneum. The dermis shows moderately dense perivascular and interstitial lymphohistiocytic cellular infiltrates in the upper dermis and lower dermis. (b) The infiltrate is admixed with neutrophils and leukocytoclasia (black arrow). The interstitial infiltrate appears to surround foci of degenerated collagen (white arrow)|
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| Discussion|| |
PNGD and IGD represent two clinicopathologic patterns of granulomatous dermatitis. Some authors use the term “reactive granulomatous dermatitis” instead of using the previous two terms.
Trunk involvement, like in the presented case, is rare.
PNGD is observed most often in patients with RA, systemic lupus erythematosus, or systemic vasculitis, particularly granulomatosis with polyangiitis (Wegener's granulomatosis and Churg–Strauss syndrome). Other underlying diseases include systemic sclerosis, Sjogren syndrome, autoimmune thyroiditis, hepatitis, inflammatory bowel disease, myelodysplastic syndrome, Takayasu arteritis, diabetes, and infections, such as Streptococcus, HIV, Epstein–Barr virus, and parvovirus.
The etiopathogenesis of PNGD is unknown. The initiating insult in PNGD may involve immune complex deposition around the walls of small dermal blood vessels as a result of the underlying disease, which leads to a subacute or chronic neutrophil-rich small-vessel vasculitis. This in turns impairs blood flow to the area; consequently, there is degeneration of the local collagen. The degenerated collagen may incite an immune response, resulting in a palisading lymphohistiocytic infiltrate. This cascade of events is likely aggravated or precipitated by exogenous trauma, which explains the predilection of PNGD lesions for the extensor surfaces.,,
The main differential diagnosis of PNGD includes IGD and rheumatoid neutrophilic dermatosis (RND) [Table 1].
|Table 1: The differentiation between palisaded neutrophilic granulomatous dermatitis, interstitial granulomatous dermatitis, and rheumatoid neutrophilic dermatosis|
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PNGD is self-limited disease in 20% of the cases. Although, in the presented case, PNGD skin lesions improved after high potency topical steroid and oral colchicine treatment, we could not conclude whether improvement was due to the drugs or spontaneous resolution of the lesions.,
Topical corticosteroids, intralesional corticosteroids, low-dose oral prednisone, colchicines, dapsone, hydroxychloroquine, nonsteroidal anti-inflammatory agents, cyclosporine, methotrexate, cyclophosphamide, infliximab, and oral tacrolimus have been reported to be effective treatment of PNGD. Treatment of the underlying disease can lead to the resolution of existing lesions. Anti-TNF treatments and allopurinol have been implicated as causes; stopping these medications can lead to resolution of the lesions.,,
Declaration of patient consent
Consent not required as the facial identity of patient has not been revealed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]