1. Actinic Granuloma (Annular Elastolytic Giant Cell Granuloma) -Report of A Case- 高雄長庚醫院皮膚科 陳毅書 郭宏文 何宜承

2. Case Report A 53 y/o male patient, with multiple erythematous to brownish, annular shaped plaques Site: forehead, neck, v-chest, bil dorsal hands (sun-exposure area) Size: about 3  5cm in diameter Number: total 8  10 Combined S/S: (-)

3. Case Report Clinical Impression –R/O Granuloma annulare, R/O sarcoidosis, R/O leprosy Skin biopsy (89/04/12) H&E stain, Verhoeff-van Gieson stain

4. Diagnosis Actinic Granuloma (Annular Elastolytic Giant Cell Granuloma)

5. Discussion Actinic Granuloma (Annular Elastolytic Giant Cell Granuloma)

6. History 1967 Dowling et al : atypical (annular) necrobiosis lipoidica of the face and scalp 1973 Mehregan et al : Miescher’s granuloma of the face 1975 O’Brien : Actinic Granuloma 1979 Hanke et al : Annular Elastolytic Giant Cell Granuloma

7. Clinical Features Sex : female predominant Age of onset: middle to old age ( >30  40y/o) Etiology: unknown, may be due to the “ cell-mediated immune response to weakly antigenic determinants on actinically altered elastotic fibers”

8. Clinical Features (Skin lesion) Single or multiple, asymptomatic, erythematous to brownish, annular to serpinginous plaques, with slowly centrifugal progression Size: millimeters to centimeters Site: –sun-exposure area : forehead, neck, v-chest, extensor site of extremities –covered area: abdomen, back (case report)

9. Histopathological Findings Elevated border: –granulomatous infiltration, histiocytes in a palisade of interstitual pattern. –multinucleated giant cell, elastotic fibers adjacent to and within the giant cells. –Asteroid body –Mucin : (-)

10. Histopathological Findings Central Zone: –near or total absence of elastic fibers (Verhoef- van Gieson stain) –collagen: scarlike appearance, slightly The zone peripheral to the annulus: –increase amount of thick elastotic metarial with the staining properties of elastic tissue

11. Differential Diagnosis Granuloma Annulare Necrobiosis Lipoidica Sarcoidosis Lupus vulgaris

12. Differential Diagnosis Granuloma Annulare –complete loss of elastic tissue in the central zone (actinic granuloma) –larger and more numerous giant cells (actinic granuloma) –mucin :actinic granuloma (-) –Necrobiosis : actinic granuloma (-) –engulfment of abnormal elastic fibers (both)

13. Differential Diagnosis Necrobiosis Lipoidica –clinical: marked atrophy, alopecia, sclerodermoid change –complete loss of elastic tissue in the central zone (actinic granuloma) –necrobiosis : sclerosis, lipids and vascular changes –deeper dermis / subcutis infiltration –multiple giant cells, asteroid body (-)

14. Differential Diagnosis Sarcoidosis –naked epitheloid tubercles –asteroid body (both) –elastolysis (actinic granuloma) –fragments of elastic fibers in multinucleated giant cells (actinic granuloma)

15. Differential Diagnosis Lupus Vulgaris –Tuberculin test : always positive –Acid-fast bacilli : can sometimes be demonstrated. –Caseation necrosis (+) –Asteroid body(-), elastic fibers in giant cells (-)

16. Treatment Topical steroid: poor response Intralesional injection of steroid : poor response Isotretinoin (0.5mg/kg/day) for 12 weeks -- case report

17. Criteria for diagnosis annular, slowly enlarging plaques develop on sun-exposed skin of patients at least 30 or 40 years of age elastotic material is present within the giantr cells, and the inflammation is granulomatous. Elastotic material and elastic fibers are absent from the postreactive central zone and greatly reduced in number and density in the vicinity of giant cells in the annular zone

18. Conclusion Actinic granuloma –A reactive process toward the abnormal elastotic tissue of the skin damaged by sun –Clinical: similar to Granuloma Annulare –Histopathology & VVG stain: special finding

19. Thank You