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To the Editor.— Granuloma faciale is a benign, chronic skin disease manifested by dusky red-brown, well-demarcated macules, plaques, or nodules, usually confined to the face. Only six patients with extrafacial lesions have been reported. 1-4 In these patients, the locations of the extrafacial lesions were on the trunk or upper extremities. We describe a patient with granuloma faciale with multiple extrafacial lesions, many of which have occurred on the lower extremities. Report of a Case.— A 57-year-old man was referred to the University of Iowa (Iowa City) dermatology clinic with a 2-year history of persistent, intermittently pruritic, red-brown plaques on his face, neck, and thighs. The first lesion developed on the anterior aspect of his neck and one or two similar lesions appeared every 2 to 4 months thereafter. Lesions have remained unchanged since onset. The patient's medical history was remarkable for a 20-year history of chronic urticaria, glaucoma, allergic

• While histopathologic analysis may offer some clues as to the pathogenesis of vasculitis, observations must be interpreted with caution, as there is considerable overlap in the histologic pattern. In most cases, a predominantly neutrophilic vasculitis affecting small dermal venules suggests a relatively acute, immune complex-mediated reaction. Less commonly, this histologic pattern may be seen in non-immunologically mediated processes, such as in the presence of bacterial toxins or malignant hypertension, or in more chronic disease states, such as granuloma faciale or erythema elevatum diutinum. A predominantly lymphocytic vasculitis may represent several pathogenetic mechanisms. In lesions more than 24 to 48 hours old, a lymphocytic vasculitis may represent a resolving phase of an immune complex-mediated neutrophilic vasculitis. Alternatively, this histologic pattern may be seen de novo in conditions with a presumed cell-mediated immunologic pathogenesis. Lymphocytic vasculitis may also be seen in rickettsial infections such as Rocky Mountain spotted fever. The pathogenesis of granulomatous vasculitis remains poorly understood and is thought to be induced by a combination of circulating immune complexes and a cell-mediated immune response. ( Arch Dermatol. 1990;126:84-89)

• Three patients with granuloma faciale were successfully treated by argon laser therapy. The intense blue-green laser light is readily absorbed by these inflammatory lesions, resulting in resolution of the clinical and microscopic abnormalities. There were no recurrences during follow-up periods of 23, 21, and 5 months, respectively. Argon laser therapy appears to be an important addition to the treatment armamentarium for this uncommon, but difficult to treat, entity. ( Arch Dermatol 1983;119:573-576)

The successful employment of carbon dioxide (CO2) laser vaporization in the treatment of granuloma faciale is described.

Cryosurgery is used effectively to treat several unusual cutaneous tumors, namely, four cases of lentigo maligna (melanotic freckle of Hutchinson, or circumscribed precancerous melanosis of Dubreuilh), one case of pseudopyogenic granuloma of Wilson Jones, and one case of granuloma faciale.

Light and electron microscopic observations were carried out in three cases of granuloma faciale. The dense granulomatous infiltrate of the corium showed: 1) more eosinophils than suspected by light microscopy, most of them with degenerative changes; 2) Charcot-Leyden chrystals; 3) numerous large histiocytes with their cytoplasms filled with lysosomal vesicles containing various inclusions (lamellar figures, myelin bodies, circular concentric organelles, digested membrane structures). The lack of Langerhans granules in dermal cells seems a valid reason to differentiate granuloma faciale from eosinophilic granuloma of the skin, usually considered a variety of histiocytosis X. No evidence of bacterial or viral infections was noticed. Granuloma faciale, despite its uncertain etiology, seems to represent a true entity.

Granuloma faciale is a presumably benign disorder of the skin--usually of the face--characterized by a dense, polymorphous, inflammatory infiltrate including numerous eosinophils, separated from the epidermis by a clear or "grenz" zone, and possessing a small vessel, leukocytoclastic vasculitis. Primary malignant lymphoma of the skin, other than mycosis fungoides, is an unusual entity that may follow a widely variable course and is often extremely difficult to diagnose definitively. A patient is presented in whom a lesion consistent with granuloma faciale changed its histological appearance and clinical behavior into that of a malignant lymphoma.

In a series of 100 adults with tinea faciei various dermatologic manifestations were mimicked, viz.: discoid lupus erythematosus in 52 patients, lymphocytic infiltration in 15, seborrheic dermatitis in 11, rosacea in 8, contacts dermatitis in 7, polymorphous light eruption in 4 and granuloma faciale in 3. Trichophyton rubrum was isolated in 78% of the respective cases, other isolated organisms being Microsporum canis (13 cases), Trichophyton violaceum in 6, Trichophyton mentagrophytes (asteroides) in 2 and Epidermophyton floccosum in 1 case. In 85% of these patients the nails were also involved by the same agent found in the lesions of the face. On the basis of these observations it is recommended that all adult patients with tinea faciei should undergo a comprehensive mycological investigation to find the primary focus, which may be an infected nail.

Various treatments have been advocated for granuloma faciale, but experience has demonstrated that cryosurgery is extremely effective and simple in application.

During a period of 8 years 300 cases of dermatophytoses involving both hairy areas and the glabrous skin were found to be caused by M. canis. There was scalp involvement in 60%, including 8 infants and 27 adults; most of the adults presented Kerion-like lesions and presented various clinical aspects such as seborrhea capitis, folliculitis and discoid lupus erythematosus. In the 21 patients showing invasion of the beard the clinical manifestations included superficial erythemato-squamous patches with hyperemic slightly elevated margins, folliculitis or abscess-like lesions and Kerion-like lesions. Among the lesions found on the glabrous skin there were unusual aspects of tinea faciei in 19 adults, mimicking lymphocytic infiltration, granuloma faciale or discoid lupus erythematosus. Some of the cases of tinea corporis found in 70 patients also had lesions simulating various other dermatological entities, including erythema multiforme, psoriasiform eruption, pityriasis rosea and seborrheic dermatitis. The hands were invaded in 5 adults patients, with involvement of the finger nails in one. Repeated mycologic examinations were necessary to establish the true etiology in many of these cases.

A 49-year-old man had a recurring intranasal mass accompanied by erythematous plaques on the forehead. Biopsy specimens of the skin and intranasal mass led to a diagnosis of granuloma faciale, a rare benign skin disorder. Lateral intranasal location and associated facial lesions help to clinically differentiate this lesion from more ominous midline granulomatous diseases. The lesions were treated with intralesional steroid injections. This may be the first reported intranasal occurrence of granuloma faciale.

Three patients with an unusual stenosing lesion affecting the upper respiratory tract are described. The lesion involved the mucosa of the nasal septum and lateral nasal wall in two cases and the mucosa of the sub-glottic region of the larynx in one. The lesion leads to thickening of the sub-mucosal connective tissues by an usual pathological process. It begins as a focal peri-vascular sub-epithelial exudate of eosinophils accompanied by collections of plasma cells and lymphocytes without fibrinoid necrosis. These foci progress to form extensive areas of peri-vascular fibrosis showing a characteristic angiocentric whorling with an 'onion-skin' pattern. This process leads to thickening and matting of the mucosa which becomes adherent to the underlying structures. As fibrosis progresses, the lympho-plasmacytic component regresses but the eosinophils remain. The fibrosis does not resolve and the consequent stenosis requires surgical relief. No other site appears to be affected by this process, but one case was associated with granuloma faciale. The cause is unknown. We have given the term 'eosinophilic angiocentric fibrosis of the upper respiratory tract' to this condition to encompass its cardinal features.

We report a case of tinea of the face caused by Trichophyton rubrum in which the histologic changes were consistent with granuloma faciale. We recommend that local infection with dermatophytes be considered in all cases of histologic granuloma faciale, especially when the clinical presentation is atypical for this dermatosis.

SUMMARY.– A case of multiple nodules of the left ear clinically misdiagnosed as granuloma faciale was found to show the histological features characteristic of subcutaneous angiolymphoid hyperplasia with eosinophilia as described by Wells and Whimster (1969). It is suggested that subcutaneous angiolymphoid hyperplasia with eosinophilia and pseudopyogenic granuloma, as described by Wilson Jones and Bleehen (1969), could represent the same disease process taking place at different tissue levels.

Letter to the editor - no abstract available

• Granuloma faciale is a well-defined entity that almost exclusively involves the face, although it has been reported in extrafacial locations. The infrequent reports of extrafacial lesions may reflect the inconspicuous nature of extrafacial lesions or a failure to specifically examine the patient for such lesions. ( Arch Dermatol 112:1575-1577, 1976)

REPORT OF A CASE A 56-year-old man had slowly proliferating and expanding asymptomatic reddish areas on his face of approximately 15 years' duration. A pink lesion first developed on his forehead, and, subsequently, multiple similar areas appeared under his left eye and on both cheeks. Most lesions remained stable, but there was some variation in progression and even rare disappearance. No specific aggravating or ameliorating agent existed. His general health was excellent, and he was taking no medications. Physical examination revealed numerous well-defined, dusky 0.5- to 3-cm erythematous papules and plaques on both malar areas, the forehead, the bridge of the nose, and the right preauricular area (Figs 1 and 2). There was follicular prominence but no follicular plugging, scarring, atrophy, or scale formation. Examination of a skin biopsy specimen disclosed a normal epidermis and a heavy polymorphous infiltrate in the upper dermis that was composed of neutrophils, lymphocytes, histiocytes

To the Editor.— The review article entitled "The Argon Laser for Cutaneous Lesions" by Apfelburg et al (1981;245:2073) was most timely. However, one might question the practicality of treating seborrheic keratoses with the argon laser. After all, these "stuck-on" nevoid excrescences are typically amenable to superficial curettage. Moreover, the authors' description of granuloma faciale as a "nonspecific dermal inflammatory fibrosis" is incorrect. Clinically, this lesion appears as an enlarging, brownish-red plaque of the face that may occasionally manifest follicular dilation. The histopathological pattern is characteristic. 1 Salient features include the presence of a Grenz zone, polymorphous inflammatory infiltrate consisting of histiocytes, lymphocytes, plasma cells, and eosinophils with evidence of leukocytoclasia, and connective tissue trabeculations adjacent to the dermal blood vessels. Therefore, granuloma faciale is a type of leukocytoclastic vasculitis and quite the antithesis of a "nonspecific" dermatopathic entity.

• A patient had facial granuloma that responded to therapy with dapsone when other treatment modalities had failed. The pathophysiologic characteristics of facial granuloma are discussed, and the possible mechanisms of action of dapsone therapy are reviewed. (Arch Dermatol1982;118:332-335)

This is the first reported case of granuloma faciale in a Negro. Bilateral infraorbital plaques showing the typical histopathologic appearance of granuloma faciale were observed in a 43-yearold Negro man. The patient also exhibited lesions on the flanks and lower extremities. The clinical and microscopic findings are discussed. Good cosmetic results were achieved by surgical excision of the infraorbital lesions and plastic repair.

A patient with granuloma faciale had multiple lesions on the face and one lesion on the dorsal surface of one hand. This case adds a clinical parallel to the recognized histological parallel between granuloma faciale and erythema elevatum diutinum.

In the February, 1947, issue of the Archives of Dermatology and Syphilology a resume, consisting of four articles, on the subject of eosinophilic granuloma of the skin, appeared. Dobes and Weidman discussed the case of granulomatous Hodgkin's disease of the skin with extreme eosinophilia. They thought that their thinking was too extreme to classify this as a case of eosinophilic granuloma but left the door open for it to qualify in the future, if such an entity as eosinophilic granuloma should be established. 1 Lewis and Cormia discussed the theoretic and practical considerations based on the study of a case of eosinophilic granuloma. 2 Lever discussed the eosinophilic granuloma of the skin in relation to erythema elevatum diutinum and eosinophilic granuloma of the bone. 3 Weidman discussed the eosinophilic granulomas of the skin. 4 In the October, 1948, Archives of Dermatology and Syphilology , Lever, Lane, Downing, and Spangler reported three

An early case of mycetoma caused by a Nocardia species is described. The lesion, which appeared on the nose, clinically resembled granuloma faciale. Response to oral sulfonamide therapy was prompt and complete. It is emphasized that an initially pustular or crusted lesion evolving into a lesion clinically resembling granuloma faciale should be carefully studied mycologically, since effective therapy of mycetomas is dependent on early and accurate diagnosis.

FROM THE extensive literature recently published concerning ``eosinophilic granuloma of the skin," there seems to have emerged a group of cases in which the disease is distinctive enough clinically, and specific enough histologically to constitute an entity. The condition has been called "facial granuloma with eosinophilia'' or ``granuloma faciale'' by Cobane, Straith, and Pinkus 1 and by Lever and Leeper 2 to differentiate it from lesions found accompanying eosinophilic granuloma of bone, with which it apparently has no connection. It is the purpose of this study further to advance the concept of this entity by describing two cases in addition to the nine already reported in the literature. REPORT OF CASES CASE1.—R. C., a 38-year-old woman, was first seen at Mount Sinai Clinic Sept. 24, 1943. At that time she presented an 0.8-by-0.8-cm. nodule on the right cheek, which had been present for one year. The lesion

We reviewed the clinical findings, histopathology, and clinical course in 21 cases of granuloma faciale. The disease can occur as macules, papules, plaques, or tumefactions, usually on the face; but the lesions may occur on other parts of the body. Children may be affected, but most cases occur in adults of middle age and older. The distinctive histopathology consists of a granulomatous infiltrate, tissue eosinophilia, and new capillary formation. The course of the disease is usually chronic with periods of slow progression alternating with intervals when the lesions remain static. There is no uniform response to any of the therapies now available, and spontaneous remission sometimes occurs.

was noted to have a reddish brown, slightly elevated, rubbery plaque measuring 1X1 cm on the right ala nasi (Fig 1). He was in good health otherwise. Serologie tests for syphilis were negative. Com¬ plete blood count was within normal limits. C-reactive protein and RA factor were negative. The liver function tests and antistreptolysin O titer were also within normal limits. The roentgenogram of the chest and the skull showed no pathologic changes. Microscopic Examination

Over the past 15 years, a distinctive facial granuloma has emerged as a clinical and histological entity. Recently, Johnson, Higdon, and Helwig have given a complete review of the disease and discussed 15 new cases. It is the purpose of this communication to present briefly a typical case, and to report a failure either to find a viral agent responsible, or to stimulate the production of a lesion on a nonfacial area. Report of a Case A 24-year-old white man developed a small, purplish, asymptomatic papule on the left side of his forehead during 1955. The lesion slowly enlarged. In June, 1959, a small papule developed more centrally on the forehead. When seen at the USAF Hospital, Lackland, in December, 1959, he was noted to have a purplishred, irregularly elevated, rubbery plaque measuring 3X2 cm. on the left side of his forehead, and a similar papule measuring 0.5 cm.

This book is an excellent summary of what is known about the benign cutaneous reticuloses. In the introductory chapter the author presents his classification of the reticuloendothelial reactions associated with cutaneous manifestations. He emphasizes that "in this classification the emphasis is on the cutaneous aspects of diseases of the reticuloendothelial system." Dr. Bluefarb has divided this group of diseases into: (a) The Inflammatory Hyperplasias—Histiocytoma, Nevoxantho-Endothelioma, Reticulohistiocytoma, Lymphocytoma . and Granuloma Faciale ; and (b) The Infectious Hyperplasias—Infectious Mononucleosis, Lymphogranuloma Venereum, Cat Scratch Disease , and Histoplasmosis . A section is devoted to each of these entities with a discussion of both the systemic and cutaneous manifestations of the disease and a review of the literature presented in a very organized manner. Dr. Bluefarb had the collaboration of Dr. Orlando Canizares, who wrote the chapters on Lymphogranuloma Venereum and Cat Scratch Disease , and Dr. Daniel S. Kushner, who contributed the chapter on Histoplasmosis . Both the