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Advances in dermatology and venereology Acta Dermato-Venereologica
Lupus Miliaris Disseminatus Faciei : Not Only a Facial Dermatosis
Marthe-Lisa SCHAARSCHMIDT 1 , Michèle SCHLICH 2 , Janina STAUB 3 , Astrid SCHMIEDER 1 , Sergij GOERDT 1 and Wiebke K . PEITSCH 4 *
1
Department of Dermatology , Venereology and Allergology , University Medical Center Mannheim , Heidelberg University , Mannheim ,
2
Dermatological Practice Dr . Krekel , Speyer , 3 Department of Dermatology and Venereology , University Medical Center , Hamburg-Eppendorf , and 4 Department of Dermatology and Phlebology , Vivantes Klinikum im Friedrichshain , Landsberger Allee 49 , DE-10249 Berlin , Germany . * E-mail : wiebke . ludwig-peitsch @ vivantes . de Accepted Jan 24 , 2017 ; Epub ahead of print Jan 25 , 2017
Lupus miliaris disseminatus faciei ( LMDF ), synonymously termed acne agminata ( 1 ), is an uncommon granulomatous inflammatory disease usually affecting the central face and the eyelids ( 1 – 3 ). Rare extrafacial manifestations have been reported ( 1 , 3 – 7 ). We present here a case of LMDF with involvement of the face , scalp and axillae and provide a summary on the characteristics of the disease and treatment options .
CASE REPORT
A 28-year-old man presented with a 3-month history of asymptomatic papules , nodules and pustules , which had initially appeared on his eyelids and in the axillae and subsequently spread over his face . Treatment with different topical agents , including antibiotics , nystatin , aciclovir and glucocorticoids , as well as oral doxycycline and oral valaciclovir , had been ineffective . The patient had no systemic symptoms or concomitant diseases and did not take any medications . He did not have any history of acne or rosacea , and denied use of aluminium-containing antiperspirants . Clinical examination showed multiple distinct red-brown , sometimes yellowish , papules and nodules , sized 2 – 10 mm , on the scalp , forehead , glabella , upper and lower eyelids , cheeks and chin ( Fig . 1a ) as well as in both axillae ( Fig . 1b ) with a light brown-yellowish infiltrate on diascopy . Diffuse erythema and telangiectasia were absent . Histopathological examination revealed dermal epithelioid cell granulomas with central caseating necrosis ( Fig . 1c , d ). Microscopy for pathogens with periodic acid – Schiff ( PAS ), Grocott and Ziehl-Neelsen stains , as well as cultures for Mycobacterium tuberculosis and atypical mycobacteria were negative . A bacterial swab yielded
Pseudomonas aeruginosa . Laboratory examinations including serum levels of angiotensin-converting enzyme and tuberculosis test with interferon gamma release assay ( QuantiFERON-TB test , QIAGEN , Hilden , Germany ) were unremarkable . Based on clinical and histopathological findings a diagnosis of LMDF with axillary involvement was established . Compatible with the results of antimicrobial susceptibility testing , a treatment attempt was made with ciprofloxacin 500 mg twice daily for 2 weeks , but without success . Subsequently isotretinoin 30 mg / day ( 0.4 mg / kg ) was initiated and continued for one year with regular laboratory monitoring . This resulted in clearing of the lesions on the face and scalp with some residual scars , but the axillary lesions remained .
DISCUSSION
LMDF usually affects young adults of both sexes , but it has also been reported in children ( 8 ) and elderly patients ( 9 , 10 ). It typically presents with yellowishbrown dome-shaped papules and pustules localized in the central face , commonly involving the eyelids ( 1 – 3 ). Moreover , extrafacial lesions in the axillae , scalp , trunk , genitalia , neck , hands and legs have been described ( 1 , 3 – 7 ). They may occur in addition to facial lesions ( 1 , 3 , 4 , 6 , 7 ) or , rarely , as the only manifestation of LMDF ( 4 , 5 ). To make allowance for lesions in non-facial sites Nemer & McGirt recently suggested renaming LMDF “ lupus miliaris disseminatus ” ( 6 ).
The papules have a yellowish-brown (‘’ apple-jelly ’’) infiltrate on diascopy . On histopathological examination
Fig . 1 . Clinical and histopathological findings . ( a , b ) Multiple red-brown and yellowish papules and nodules in the face , on the scalp and in the axilla . ( c , d ) Haematoxylin-eosin stained skin biopsy specimen from the face showing dermal epithelioid cell granulomas with central areas of caseating necrosis . Magnification : ( c , survey ) × 20 or ( d , detail ) × 100 . A biopsy from the axilla yielded identical findings . Written permission is given to publish these photographs .
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2017 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2616 Acta Derm Venereol 2017 ; 97 : 655 – 656