Granulomatous periorificial dermatitis

Granulomatous periorificial dermatitis (GPD) is a distinct facial eruption in prepubertal children that should be distinguished from granulomatous rosacea, perioral dermatitis, and cutaneous sarcoidosis. We describe a case of GPD and review the key distinguishing features of this condition.     

Childhood Granulomatous Periorificial Dermatitis with a Good Response to Oral Metronidazole

Childhood granulomatous periorificial dermatitis (CGPD) is a condition included in the spectrum of rosacea and perioral dermatitis that affects prepubescent children. It is characterized by papular eruptions located around the mouth, nose, and eyes that histopathologically show a granulomatous pattern. We report a 9‐year‐old girl with CGPD who required treatment with an oral antibiotic. Oral metronidazole was administered because of its known efficacy in adult rosacea and its safety in children. The patient responded well to this therapy, showing resolution of the lesions.     

Periorificial dermatitis due to systemic corticosteroids in children: report of two cases

Periorificial dermatitis is a common acneiform eruption that is thought to represent a variant of rosacea. These patients typically present with uniform erythematous papules most commonly located periorally but also occurring around the nose and eyelids. This eruption has been linked to topical corticosteroid use, with only a few reports in the literature associated with systemic steroid use in adults. Here, we report two cases of periorificial dermatitis occurring after systemic corticosteroid use in children.     

A case of granulomatous rosacea: sorting granulomatous rosacea from other granulomatous diseases that affect the face

Granulomatous rosacea is a variant of rosacea that may present similar to other granulomatous diseases. We present the case of a 45-year-old woman with a 2-year history of facial erythema with multiple papules and pustules on the cheeks, chin, and glabella. The patient responded to minocycline, resulting in healing 6 months without residual scarring. This patient's clinical and histological presentation and treatment outcome are to our assessment consistent with granulomatous rosacea. However, other clinically and histologically related entities will be discussed. These entities include, but are not limited to, perioral dermatitis, granulomatous periorificial dermatitis, lupus miliaris disseminatus faciei, facial afro-caribbean eruption syndrome, and sarcoidosis.     

Pediatric ocular rosacea,a misdiagnosed disease with high morbidity: Proposed diagnostic criteria

Ocular rosacea is an important and underdiagnosed chronic inflammatory disorder observed in children. A clinical spectrum ranging from chronic eyelid inflammation, recurrent ocular redness, photophobia and/or hordeola/chalazions and conjunctival/corneal phlyctenules evolving to neovascularization and scarring may occur. Visual impairment and consequent amblyopia are frequent and corneal perforation although rare is the most feared complication. Ocular manifestations usually precede cutaneous lesions. Although few cases of pediatric ocular rosacea (POR) have been reported in the literature, many cases must have been underdiagnosed or misdiagnosed. The delay in diagnosis is greater than one year in the large majority of cases and may lead to serious ocular sequelae. This review aims to highlight the clinical features of POR, its epidemiology, easy diagnosis and effective treatment. We also propose new diagnostic criteria, in which at least three of the five clinical criteria must be present: (1) Chronic or recurrent keratoconjunctivitis and/or red eye and/or photophobia; (2) Chronic or recurrent blepharitis and/or chalazia/hordeola; (3) Eyelid telangiectasia documented by an ophthalmologist; (4) Primary periorificial dermatitis and/or primary features of rosacea; and (5) Positive familial history of cutaneous and/or ocular rosacea.     

Childhood granulomatous periorificial dermatitis: lupus miliaris disseminatus faciei in children?

BACKGROUND: Childhood granulomatous periorificial dermatitis (CGPD) is a granulomatous disease characterized by monomorphous, small papular eruptions around the mouse, nose and eyes, and is thought to be closely related to perioral dermatitis. This condition has always been believed to occur more commonly in dark-skinned patients; however, recent observations have revealed CGPD to occur also in white patients. OBSERVATION: We report an 11-year-old Japanese boy with the characteristic features of CGPD. Although sarcoidosis and acne/granulomatous rosacea could be differentiated from CGPD, we could find no essential differences between CGPD and lupus miliaris disseminatus faciei (LMDF). The cases of LMDF in children, which were recorded in the Japanese literature, had highly similar clinicopathological features to those of CGPD. This case responded dramatically to topical tacrolimus in combination with the oral administration of minocycline. CONCLUSIONS: The entity 'facial idiopathic granulomas with regressive evolution' is considered to include LMDF (a common adult form), CGPD (a rare childhood form) and perioral dermatitis (a peculiar form exacerbated by topical corticosteroids). Topical tacrolimus may be recommended as one of the therapies for LMDF as well as CGPD.     

Pediatric rosacea

Rosacea is a condition most commonly associated with adults; however, various forms exist in the pediatric population and need to be considered when a child presents with a facial rash. Acne rosacea, steroid rosacea, granulomatous periorificial dermatitis, and other variants of rosacea are presented here and are distinguished from their numerous mimickers. Various topical and systemic therapeutic options exist for the treatment of rosacea with several adjustments and considerations that must be taken into account when treating a child.     

Acneiform eruptions

Is it acne or is it not? When this question arises, we can presume that we have crossed the boundaries of “acneiform eruptions” of the face. Although acne may be considered a condition fairly easy to diagnose, it is not rare for the practicing dermatologist or the general physician to wonder when faced with an acneiform eruption before establishing a diagnosis. In this review, we address facial acneiform eruptions in children and in adults, including perioral dermatitis, granulomatous periorificial dermatitis, nevus comedonicus, acne cosmetica, rosacea, demodicosis, folliculitis, acneiform presentation of cutaneous lymphomas, and drug-induced [epidermal growth factor receptor (EGFR) inhibitors, steroids, etc] acneiform eruptions, along with their diagnosis and therapeutic approaches. The major distinguishing factor in acneiform eruptions is that, in contrast to acne, there are no comedones (whiteheads or blackheads).     

Perioral dermatitis in children.

Perioral dermatitis is a unique skin disorder of childhood. Its exact origin is unknown; it is probably an idiosyncratic response to exogenous factors such as the use of a topical fluorinated corticosteroid or other substances on the face. It is uncommon but not rare. The age of affected children has ranged from 7 months to 13 years, with the median being in the prepubertal period. Boys and girls, blacks and whites are equally affected. Clinical features include the following: (1) absence of systemic symptoms; (2) periorificial distribution (perioral, perinasal, periorbital); (3) skin lesions that consist of flesh colored or erythematous inflammed papules, micronodules, and rare pustules; and (4) variable pruritus. Laboratory tests are negative. Histologically, it is indistinguishable from rosacea; there is a superficial perifollicular granuloma consisting of epitheliod cells, and lymphohistiocytic infiltrate, with occasional giant cells. The disease waxes and wanes for weeks and months. Treatment consists of discontinuing topical fluorinated corticosteroid use if any, and using topical metronidazole alone or in combination with either oral tetracycline or erythromycin depending on the child's age. A low-potency topical steroid may also be used to suppress the inflammation and to wean off the strong steroid. Perioral dermatitis in childhood is probably a juvenile form of rosacea.     

Granulomatöse periorifizielle Dermatitis der Kindheit

Case report

A 14-year-old patient of African ancestry presented with multiple papules in the perioral, perinasal and periocular areas. Histopathology showed sarcoidal granulomas.

Diagnosis

After exclusion of systemic sarcoidosis, the diagnosis of childhood granulomatous periorificial dermatitis was made.

Therapy

Topical treatment with erythromycin resulted in complete regression.

Conclusion

Childhood granulomatous periorificial dermatitis is mainly observed in dark-skinned children of African, Caribbean, or Asian origin. The nosological position of the dermatosis is controversial. Originally classified as sarcoidosis, childhood granulomatous periorificial dermatitis is now generally regarded as a special form of perioral dermatitis.     

Extrafacial and generalized granulomatous periorificial dermatitis

BACKGROUND: Granulomatous periorificial dermatitis is a well-recognized entity presenting most commonly in prepubertal children as yellow-brown papules limited to the perioral, perinasal, and periocular regions. The condition is self-limiting and is not associated with systemic involvement. OBSERVATIONS: We reviewed the medical charts of 5 healthy children presenting with extrafacial granulomatous papules in addition to the typical periorificial papules. These extrafacial lesions were clinically and histologically identical to the facial lesions, were self-limiting, and were not associated with systemic involvement. Resolution seemed to be hastened with the use of systemic antibiotic therapy in 4 of the 5 patients. CONCLUSIONS: Extrafacial lesions can occur in granulomatous periorificial dermatitis and do not appear to adversely affect the duration, response to therapy, or risk of extracutaneous manifestations. Overly aggressive evaluation and inappropriate systemic therapy should be avoided.     

Perioral dermatitis

Perioral dermatitis is a relatively common inflammatory facial skin disorder that predominantly affects women. It is rarely diagnosed in children. A typical perioral dermatitis presentation involves the eruption of papules and pustules that may recur over weeks to months, occasionally with fine scales. The differential diagnosis includes seborrheic dermatitis, systemic lupus erythematosus, acne vulgaris, lupus miliaris disseminatus faciei, polymorphous light eruption, steroid-induced rosacea, granulomatous perioral dermatitis, contact dermatitis (allergic and irritant), and even basal cell carcinoma. The histopathology is similar to that of rosacea, with a perivascular and perifollicular lymphohistiocytic infiltrate and sebaceous hyperplasia. The etiology of perioral dermatitis is unknown, but the uncritical use of topical corticosteroids often precedes skin lesions. Physical sunscreens with high sun protection factors may cause perioral dermatitis in children.     

Steroid‐induced Periorificial Dermatitis in Children—Clinical Features and Response to Azelaic Acid

Abstract: Periorificial dermatitis, a common skin disease in young women, has been occasionally reported in children. This study elaborates the clinical features of periorificial dermatitis in children as well as possible pathogenetic factors and the response to 20% azelaic acid cream. A total of 10 children aged 3 to 12 (mean 7.7) years suffering from nongranulomatous periorificial dermatitis for 3 to 7 (mean 4.9) months were evaluated, and dermatologic examination was carried out. Pretreatment was documented. Skin prick tests with a panel of six common inhalative allergens and patch tests with the European Standard Series were performed. An association between atopy and periorificial dermatitis was evaluated, and patients were screened for skin colonization by fungi, bacteria, and Demodex mites. They were treated with 20% azelaic acid cream, which was topically applied twice daily on all affected areas, until complete resolution was achieved. Treatment period was followed by an individual observation period. Periorificial dermatitis had developed in typical distribution and morphology. In all patients, low‐ to high‐potency topical corticosteroids had been used on the face prior to manifestation. Atopy was found in half of the patients. Allergological, bacteriological, and mycological examinations did not reveal pathologic results. Demodex mites could not be demonstrated by skin surface biopsy. Treatment with 20% azelaic acid cream led to complete resolution of skin lesions after 4 to 8 (mean 5.4) weeks in all patients. Transient exacerbation of skin condition with a peak between the 2nd and 6th day of treatment could be observed in three patients. Side effects of 20% azelaic acid cream were registered in six patients and were predominantly present in the first 2 weeks of treatment. Side effects were minimal and became rarer with ongoing treatment. No recurrences were seen within a follow‐up period of 2 to 8 (mean 4.4) months. Treatment with 20% azelaic acid cream could provide an effective and safe alternative therapeutic option in children with nongranulomatous periorificial dermatitis.     

A ROSACEA-LIKE ERUPTION OF CHILDREN

Eleven children have shown similar changes on the facial skin. A bright malar flush was accompanied at times by small superficial papules, pustules and scaling. The clinical picture was variable, sometimes closely resembling rosacea and sometimes peri-oral dermatitis, taking an average of 1 year to clear. Seven of the 11 children had a family history of atopy, and 2 had a family history of rosacea. Potent topical corticosteroids may have played a role in the cause of these children's rash and, on withdrawal, there was sometimes a pustular exacerbation. The relationship to rosacea and peri-oral dermatitis is discussed.     

Childhood Granulomatous Periorificial Dermatitis

Abstract: A case of childhood granulomatous periorificial dermatitis is described. This disorder occurs predominantly in prepubertal black children and is characterized by a monomorphous, papular eruption occurring around the mouth, nose, and eyes. It is benign and self-limited. Treatment may include topical metronidazole in young patients and tetra-cycline in those over 8 years of age.     

Lupoide Rosazea als Sonderform der Rosazea

Lupoid or granulomatous rosacea is classified as a special form of rosacea which along with the typical rosacea symptoms features monomorphic yellow-brown and red papules and nodules on the cheeks and periorificial areas. Histology shows noncaseating epithelioid cell granulomas with surrounding mononuclear cell infiltrates. It is difficult to treat. Currently, the only officially approved systemic treatment is tetracycline. However, there is a broad experience with off-label use of isotretinoin (10-20 mg daily). We describe a patient with an excellent response to 20 mg isotretinoin daily.     

Cutaneous manifestations of methylmalonic and propionic acidaemia: a description based on 38 cases

Methylmalonic and propionic acidaemias are rare metabolic disorders with an autosomal recessive mode of inheritance. A number of aminoacidopathies may have cutaneous manifestations, but these are usually absent in methylmalonic and propionic acidaemia. We have studied 38 children with propionic and methylmalonic acidaemia in the last 10 years at the Hôpital Necker-Enfants Malades. Thirteen had cutaneous manifestations: acute superficial scalded skin and superficial desquamation, bilateral and periorificial dermatitis, psoriasiform eruptions, and alopecia. The relative uniformity of these manifestations (scalded skin and desquamation after metabolic decompensation, chronic bilateral and periorificial dermatitis) suggests that methylmalonic and propionic acidaemias should be included in the category of aminoacidopathies with cutaneous manifestations. All these patients were suffering from severe forms of these diseases, with no residual enzyme activity, and they were all subjected to a very severe natural protein-restricted diet. These cutaneous manifestations may therefore either be part of a complex multideficiency syndrome, or be due to the enzyme deficiency itself.     

Recalcitrant granulomatous periorificial dermatitis with good response to low‐dose oral isotretinoin

Granulomatous periorificial dermatitis is a clinical variant of periorificial dermatitis. We present the case of an 18‐year‐old girl with several reddish papular lesions in the perioral, perinasal, and periorbital regions unresponsive to conventional therapy. After 6 months of therapy with low‐dose oral isotretinoin, the lesions fully remitted.     

Therapieresistente granulomatöse rosazeaähnliche Dermatitis bei einem 9-jährigen Mädchen

A 9-year-old female developed facial papules and pustules since four years. Clinically, perioral dermatitis was suspected. Different topical therapy regimens and systemic anibiotics had been unsuccessful and a skin biopsy showed granulomatous (lupoid) rosacea. Only systemic antibiotic treatment with minocyclin led to healing of the skin lesions. While granulomatous rosacea-like dermatitis is more frequently diagnosed in adults, it is only rarely encountered in children where, in most of the cases, it represents a therapeutic challenge.     

Perioral dermatitis

Perioral dermatitis is a relatively common inflammatory disorder of facial skin, often appearing in patients with rosacea, but with less inflammation. A typical perioral dermatitis presentation occurs with the eruption of papules and pustules confined to the nasolabial folds and the skin of the chin. Clinically, small pink papules and pustules may recur over weeks to months, sometimes with fine scales. The differential diagnosis includes seborrheic dermatitis, systemic lupus erythematosus, acne vulgaris, lupus miliaris disseminatus faciei, steroid-induced rosacea, and even basal cell carcinoma. The histopathology is similar to that found in rosacea. With advancement of the process, a perivascular and perifollicular lymphohistiocytic infiltrate develops. Sebaceous hyperplasia may be prominent in some patients. The most severe forms of disease show perifollicular noncaseating epithelioid granulomas. Treatment may include topical metronidazole as for rosacea (once or twice daily), azelaic acid cream, benzyl peroxide preparations, and to a lesser degree, topical erythromycin, clindamycin, or tetracycline. Oral tetracycline, doxycycline, or minocycline may also be helpful in presentations that are more resistant.