Case Number : Case 1332 - 31 July Posted By: Guest

Interstitial granuloma annulare vs. dermal contact dermatitis.

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[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case%201332%20-%20RAC7097x40_Perls_4pm.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case%201332%20-%20RAC7097x5_EVG_4pm.jpg[/img]

Have been struggling a lot with this case !!
I think the clue is in the EVG.. The EVG is highlighting proliferation of elastic fibers in the papillary dermis together with amorphous masses of elastotic material in the dermis.
Now after this, looking again on the H&E again, may be we r dealing with solar elastosis with the dermal cleft being bullous solar elastosis... Hemorrhage and extravasated erythrocytes is not uncommon around bullous solar elastosis, Pearl's positivity indicates that the brown deposits seen are hemosiderin depositis secondary to the dermal hemorrhage. I have read in Weedon about chronic heliodermatitis with perivascular lymphohistiocytic infiltrate associated with solar elastosis in chronic actinic damaged skin. It is usually associated with mast cells which I can not c here.
I do not know if I am interpreting it right with the weird clinical presentation!!

After seeing the new photographs and reading Mona's comments I agree with her suggestion of bullous solar elastosis.

I have made some research and came up with this lovely case presentation of bullous solar elastosis.. I think the clinical photos here mimics the description in the history above given by Dr Carr.. However, I do not think it resolves completely within few days may be just the associated inflammation subsides a bit and re-exacerbates with sun exposure ???

http://www.globalskinpathatlas.com/imagedetail.cfm?topLevelID=77&imageID=595&did=1429

Remember seeing once a pathological demonstration of bullous solar elastosis in a Dermatopathology meeting but have never seen this clinically before !!!!

Marvelous :-))

Wow…have to say Mona's assessment appears spot on! Was struggling with this one!!

Although bullous solar elastosis seems fitting well, I wonder about the rapid resolution of the lésions as regards chronic nature of this condition! Upon searching, I found that early lesions of erythema ab igne are reversible. It's characterized by mid dermal collections of solar elastotic material associated with few hemosiderin(+ ve Pearl) and melanin. Bullous forms are reported but can't find reported dermal clefts! I think the clinical picture will be the discriminating factor.

My report:
Marked background solar elastosis, mid to upper dermal fibrin pseudocyts with RBC & iron - suggest traumatic shearing force. Focal mild spongiosis moderate perivascular lymphoytic infiltrate with eosinophils. Consider arthropd, drug and less likely contact dermatitis.

Thanks Mona I think the description of bullous solar elastosis fits quite well. I was thinking that there was probably an underlying inflammatory dermatosis (moderate perivascular lymphocytic infiltrate and scattered eosinophils) that probably led to the local trauma (scratching etc) or a shearing force. In this anatomic location and age skin is often composed of mainly elastic fibres with very little collagen so with the added solar elastosis I suppose it is very susceptible to local trauma.