Granulomatous skin disease with a histological pattern of palisading granuloma – an atypical facial necrobiosis lipoidica or more?

A 56-year-old woman was admitted to the Department of Dermatology due to the presence of disseminated patches on the skin of the face, and some sharply demarcated atrophic plaques on the skin of the right forearm and her left shin. Initially, the skin lesions had appeared on the left temple ca. 15 years ago, reportedly after a prolonged sun exposure. According to the patient, the lesions were erythematous, annular and non-itchy. Three years later, the aforementioned patches had appeared on the right half of the face, covering the skin of the temple, cheek and the nose. Seasonal aggravation of the skin symptoms during the summer months, as well as gradual resolution of the lesions during the autumn and the winter had been observed. Furthermore, a small asymptomatic patch had appeared on the dorsal side of the right shin ca. 10 years ago, and had been enlarging gradually throughout the years. Eventually, these lesions progressed to a sharply demarcated, yellow-brown atrophic plaques (Figure 1).
The patient’s medical history included hypertension, treated with -blockers, angiotensin converting enzyme – inhibitor (ACEI), salicylic acid and proton-pump inhibitors (PPI). The patient also reported occasional arthritis of peripheral joints with tenderness and swelling. Rheumatoid arthritis was excluded based on the laboratory findings and X-ray examination.
In 2012, the patient underwent hospitalization at the dermatological ward of the district hospital. Biopsy material from the right arm skin lesion was taken for analysis purposes. Histological examination revealed a vacuolation of the basal epidermis, plus an inflammatory infiltration around the superficial and deep vessels in the dermis, as well as around the hair follicles. According to the pathologist, the histological pattern implied lupus erythematosus, however the finding was not evident. Indirect immunofluorescence of the serum did not reveal the presence of anti-nuclear antibodies (ANA). Based on the presence of discoid skin lesions, both on the face and the forearm, occasional arthritis, aggravation after the previous sun exposure, leukopenia (3.2–3.76 × 103/µl) and the result of the skin biopsy, discoid lupus erythematosus was diagnosed. The treatment with antimalarial medications (hydroxychloroquine) was prescribed and avoidance of sun exposure combined with everyday use of SPF creams was also recommended.
On the day of admission, the aforesaid sharply demarcated patches located...


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