A 65‐year‐old man presented to the Dermatology Outpatient Department complaining of an eruption of 10 years’ duration. He also suffered from hypertension, coronary artery disease, and diabetes mellitus for which he received mononitrate isosorbide, propranolol, nifedipine, aspirin, and glimepinide; he showed well‐controlled hypertension and blood glucose.
He had consulted several dermatologists since the appearance of the eruption. A diagnosis of cutaneous leishmaniasis had been made. Although the diagnosis had not been confirmed by histology, the patient had received injections of steroids without any apparent improvement.
On clinical examination, the eruption was noticed on the front and anterior area of the scalp (Fig. 1). It consisted of pink‐ to red‐colored papules, which had become confluent and formed large plaques. The lesions had extended with time and were totally asymptomatic.
Figure 1
Clinical appearance at initial consultation
The chronic course of the eruption prompted the performance of a biopsy. Histologic examination of the lesions revealed a slight spongiotic epidermis, below which a zone deprived of cells (Grenz zone) was found. Beneath the Grenz zone, there was a dense, diffusely distributed dermal accumulation of inflammatory infiltrate (Fig. 2), consisting of lymphocytes, eosinophils, histiocytes, and a small amount of nuclear dust. Deposits of eosinophilic material were observed around the walls of some vessels. Direct immunofluorescence revealed fibrinogen and complement C3 on the walls of some vessels. The histologic picture was considered by the pathologist to be compatible with granuloma faciale.
2
Histology of a skin lesion from the anterior area of the scalp. An intense inflammatory infiltrate is evident beneath the Grenz zone
Full blood count examination was within normal levels. Blood glucose, urea, creatinine, and liver enzymes were also found to be within normal levels, but serum ferrum was far below the normal value at 11 µg (normal range, 53–167 µg). Ferritin was normal. Although there were no complaints of any associated underlying disease, tumor markers were evaluated. Of the tumor markers, only specific prostatic antigen far exceeded normal levels, with a value of 11.24 ng (normal range, 0–4.0 ng), a result that led to a urology consultation.
Prostate examination revealed an edematous, enlarged prostate with a nodule on the left prostate lobe. A biopsy was taken and showed a well‐differentiated prostate adenocarcinoma, Gleason's grade 3.
Due to the presence of coronary artery disease, antiandrogen therapy of the prostate adenocarcinoma was first‐choice treatment. Antiandrogen therapy consisted of cyproterone acetate, 300 mg intramuscularly every 2 weeks, and leuproreline acetate, 3.75 mg intramuscularly once a month. With this therapy, within 2 months and parallel to the regression of the tumor, a significant improvement in the skin lesions was noted (Fig. 3).
3
Granuloma faciale in regression under antiandrogen therapy
