Abstract:

A 69-year-old Hispanic female presented for re-evaluation of a scar. Three years prior, the patient had two adjacent squamous cell carcinomas which were treated with Mohs surgery resulting in one linear closure. Shortly thereafter, she was found to have an asymptomatic, 40 x 7 mm well-demarcated brownish-red, thin, rectangular plaque to her right cheek with large telangiectasias and a parallel thin scar in the center. It had been treated once with pulse dyed laser with no improvement. The left cheek was also noted to have a new reddish-brown papule with branching telangiectasias concerning for a basal cell carcinoma and was biopsied for diagnosis. Unexpectedly, pathology showed a dense mixed dermal inflammation as well as a Grenz zone with areas of early fibrinoid vasculitis consistent with granuloma faciale (GF). A review of the previous biopsies revealed two shave biopsies that also had mixed dermal inflammation and Demodex which were attributed to rosacea. In the context of all the biopsies, it was determined the persistent plaque surrounding the Mohs scar was also granuloma faciale. GF is typically a chronic condition seen most often on the forehead, cheeks, and nose of middle-aged white men and is thought to represent a chronic leukocytoclastic vasculitis. Etiology is unclear but trauma like in this case from the Mohs surgery may be a culprit. Histopathology is often needed for diagnosis and will have the presence of Grenz zone, mixed inflammation of neutrophils, lymphocytes, plasma cells, and eosinophils, and vascular changes with mainly perivascular infiltrate. Treatment is difficult but may include intralesional or topical steroids, calcineurin inhibitors, lasers, excision, and cryosurgery; but many still carry the risk of dyspigmentation, scarring, and recurrence. This case highlights the importance of both clinical and pathology in diagnosis and that a broad range of differentials should still be considered in patients who present with atypical scars.

Financial Disclosure:
No current or relevant financial relationships exist.

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Aeja Weiss