• Users Online: 155
  • Print this page
  • Email this page


 
 
Table of Contents
CASE REPORT
Year : 2020  |  Volume : 24  |  Issue : 1  |  Page : 54-56

Palisaded neutrophilic granulomatous dermatitis: Case report and review of literature


1 Department of Dermatology, King Abdul Aziz Hospital, Makkah, Saudi Arabia
2 College of Medicine, Umm AlQura University, Makkah, Saudi Arabia

Date of Submission20-Sep-2019
Date of Acceptance26-Nov-2019
Date of Web Publication27-Mar-2020

Correspondence Address:
Dr. Khalid Al Hawsawi
House #4148, Al-Takassosi District, Branch #6134, Unit #1, Makkah 24323
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_55_19

Get Permissions

  Abstract 


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 Oct 20];24:54-6. Available from: https://www.jddsjournal.org/text.asp?2020/24/1/54/281428




  Introduction Top


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.[1] 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.[1],[2] 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 Top


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

Click here to view
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)

Click here to view



  Discussion Top


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.[1]

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.[3],[4],[5]

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

Click here to view


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.[1],[2]

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.[6],[7],[8]

Declaration of patient consent

Consent not required as the facial identity of patient has not been revealed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Piette WW. Rheumatoid arthritis, juvenile idiopathic arthritis, adultonset still disease, and rheumatic fever. In: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, et al., Fitzpatrick's Dermatology. 9th ed. Vol. 1. New York: McGraw Hill; 2019. p. 1148-9.  Back to cited text no. 1
    
2.
Kalen JE, Shokeen D, Ramos-Caro F, Motaparthi K. Palisaded neutrophilic granulomatous dermatitis: Spectrum of histologic findings in a single patient. JAAD Case Rep 2017;3:425-8.  Back to cited text no. 2
    
3.
Mahmoodi M, Ahmad A, Bansal C, Cusack CA. Palisaded neutrophilic and granulomatous dermatitis in association with sarcoidosis. J Cutan Pathol 2011;38:365-8.  Back to cited text no. 3
    
4.
Finan MC, Winkelmann RK. The cutaneous extravascular necrotizing granuloma (Churg-Strauss granuloma) and systemic disease: a review of 27 cases. Medicine (Baltimore) 1983;62:142-58.  Back to cited text no. 4
    
5.
Sangueza OP, Caudell MD, Mengesha YM, Davis LS, Barnes CJ, Griffin JE, et al. Palisaded neutrophilic granulomatous dermatitis in rheumatoid arthritis. J Am Acad Dermatol 2002;47:251-7.  Back to cited text no. 5
    
6.
Chu P, Connolly MK, LeBoit PE. The histopathologic spectrum of palisaded neutrophilic and granulomatous dermatitis in patients with collagen vascular disease. Arch Dermatol 1994;130:1278-83.  Back to cited text no. 6
    
7.
Biswas A, Chittari K, Gey van Pittius D, Stephens M, Tan BB. Palisaded neutrophilic and granulomatous dermatitis in a child with type I diabetes mellitus and coeliac disease. Br J Dermatol 2008;159:488-9.  Back to cited text no. 7
    
8.
Bremner R, Simpson E, White CR, Morrison L, Deodhar A. Palisaded neutrophilic and granulomatous dermatitis: An unusual cutaneous manifestation of immune-mediated disorders. Semin Arthritis Rheum 2004;34:610-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed682    
    Printed56    
    Emailed0    
    PDF Downloaded106    
    Comments [Add]    

Recommend this journal