Case of the Month

30 year old woman presents with a 6 month papular rash around the mouth. Topical antibiotics and topical steroids have been of little help.

Here are the photomicrographs of the biopsy:

Lupus miliaris disseminatus facei

Here is the pathologic report prepared by Erick Jacobson, MD, board certified dermatopathologist: Histologic sections demonstrate a punch biopsy of skin with a relatively unremarkable overlying epidermis. Within the superficial dermis is a perifollicular chronic granulomatous inflammatory infiltrate with a focus of necrobiosis. Supportive inflammation is absent. Deeper sections were performed and reviewed. PAS and Gram stains are negative for microorganisms. Polarization is negative for birefringent material.

The findings are most compatible with the clinical impression of lupus miliaris disseminates fascia.

Lupus miliaris disseminatus faciei (LMDF), is a rare papular eruption that occurs on the face.

It has also been called:

• Acne agminata
• Acnitis
• Figure (Facial Idiopathic Granulomas with Regressive Evolution)

Earlier on, LMDF, (because of it histologic granulomas) was believed to be a sub-type of cutaneous tuberculosis. Of course,that is no longer believed to be true. Additionally, some believe the condition to be a variant of granulomatous rosacea, or even a variation of sarcoidosis.

Most commonly, LMDF is now believed by some, to be a distinct entity. One prominent histologic feature, in addition to granulomas, is the presence of necrobiosis. There are several other entities, (including LMDF) that I believe to be closely related and may in fact be variations of each other. I tend to be more of a ‘lumper’ rather than ‘splitter’, and I do recognize that there are differing opinions. Never-the-less, I believe these to include severe perioral dermatitis (non-steroid related) Facial Afro-Caribbean Childhood Eruption (FACE), and facial granulomatous eruption of childhood.

LMDF affects adolescents and adults, both men and women. LMDF usually resolves on its own in 1-3 years with notable pitted scarring. Unfortunately, no one wants bumps on their face for 1-3 years that turns onto pitted scars, so in my practice I have had very satisfactory results using oral antibiotics, isotretinoin and both topical and oral dapsone. Topical steroids had been remarkably ineffective in my experience.