Actinic Granuloma?

“Ring-shaped inflammatory lesions sometimes develop in the abnormal, ‘elastotic’ connective tissue of the skin damaged by the sun and heat …”

“Microscopic sections show that there is an infiltrate composed mainly of foreign-body giant cells, the cells being engaged in digesting and absorbing the abnormal elastotic fibers …”

“The name actinic granuloma indicates its external or environmental origin and distinguishes it from other granulomas with which it is constantly being confused.”
O’Brien P. Actinic granuloma: an annular connective tissue disorder affecting sun and heat damaged (elastotic) skin. Arch Dermatol 1975;111:460-66.

“Based on histomorphology, we believe that actinic granuloma should be considered a separate, independent condition and should be distinguished from granuloma annulare even in sun-exposed areas of skin.”
Al-Hoqail IA, Al-Ghamdi AM, Martinka M, et al. Actinic granuloma is a unique and distinct entity: a comparative study with granuloma annulare. Am J Dermatopathol 2002;24:209-12.

In 1975, O’Brien, an Australian general pathologist, described what he considered to be a specific disease induced by longstanding exposure to rays of the sun characterized clinically by annular lesions and typified histopathologically by granulomatous inflammation associated with elastophagocytosis, i.e., ingestion of elastotic fibers by macrophages. O’Brien, and some students of the subject subsequent, remarked that the lesions clinical resembled those of granuloma annulare. Because of elastophagocytosis, and that finding alone, O’Brien averred that the granulomatous dermatitis was unique, and he named it “actinic granuloma.” In our estimation, all of the attributes noted by O’Brien were those of granuloma annulare, including the elastophagocytosis. Ingestion of elastic and elastotic fibers by macrophages is a phenomenon devoid of specificity, one that may occur in circumstances as disparate as granuloma annulare, an inflammatory disease, and granulomatous slack skin, a lymphoma, to wit, mycosis fungoides.

For elastophagocytosis to come into being, damage first must be done to elastic or elastotic fibers, that injury making them appetizing to macrophages. Alteration of those fibers probably is a consequence of the effects of elastases manufactured by inflammatory cells, such as by neutrophils in cutis laxa and neoplastic lymphocytes in mycosis fungoides. Only after elastic and/or elastotic fibers have been changed chemically is the stage set for them to be ingested by macrophages. It is not surprising, therefore, that elastophagocytosis is seen commonly in lesions of granuloma annulare situated in skin damaged badly by sunlight, given the fact that lymphocytes are present around venules and histiocytes are disposed in palisaded and interstitial array.

Granuloma annulare varies greatly in appearance clinical and in distribution regional. Lesions may be papular and missing any hint of an annulus or they may assume the striking configuration of rings. Some lesions may be eroded and crusted (perforating granuloma annulare), whereas others may be seated beneath the skin (subcutaneous granuloma annulare). Although lesions of granuloma annulare tend to favor sites covered by clothing, one expression of it is confined to sites exposed to rays of the sun. Histopathologically, cutaneous granuloma annulare, irrespective of manifestation clinical, displays superficial and deep perivascular infiltrates of lymphocytes in conjunction with histiocytes distributed either in palisaded or interstitial arrangement, or both of them together. When elastic or elastotic fibers devoured by macrophages are observed in lesions characteristic of granuloma annulare, the diagnosis should be granuloma annulare, not actinic granuloma, which to most dermatologists denotes something other than granuloma annulare.

In the analysis ultimate, the diagnosis morphologic of skin diseases must take into account both attributes gross and microscopic. One of those sets is not more important than the other. If clinically a lesion is granuloma annulare and histopathologically it shows all of the findings of granuloma annulare, then the diagnosis is granuloma annulare, irrespective of the presence or absence of elastophagocytosis, “perforation” of degenerated collagen, fibrin, and mucin through the epidermis, or nuclear “dust” of neutrophils in the center of palisades of epithelioid histiocytes. Reasoning specious about findings histopathologic has led to debates about whether lesions were truly those of necrobiosis lipoidica diabeticorum, on one hand, or of granuloma disciformis, on the other; of granuloma annulare on the face or of Miescher’s granuloma of the face; of erythema elevatum diutinum or of extracellular cholesterolosis; of erythema nodosum or of subacute nodular migratory panniculitis; and of long-standing suppurative infundibulitis complicated by imposition of prurigo nodularis or of hyperkeratosis follicularis et parafollicularis in cutem penetrans. “Diseases” that are not authentic do not stand the test of time, and, for that reason, diagnoses of granuloma disciformis, Miescher’s granuloma of the face, extracellular cholesterolosis, subcutaneous nodular migratory panniculitis, and hyperkeratosis follicularis et parafolliculars in cutem penetrans hardly ever are made nowadays by knowledgeable dermatologists or general pathologists. Neither do students of skin diseases hear anymore of Weber-Christian syndrome and Rothman-Makai disease, and neither should they hear of toxic epidermal necrolysis and Spiegler-Fendt sarcoid. The same fate is inevitable for “actinic granuloma” because what is called actinic granuloma is granuloma annulare.

“Let me admit to being perplexed by the ‘gray’ states that exist between granuloma annulare and actinic granuloma.”
O’Brien JP. Is actinic granuloma a specific condition? Am J Dermatopathol 1979;1:51–53.

“The concept of an actinic granuloma as proposed by O’Brien would seem justified both clinically and histologically and there would seem to be no reason why the entity should be submerged under the general title of granuloma annulare as proposed by Ragaz and Ackerman in 1979.”
Prendiville J, Griffiths WA, Jones RR. O’Brien’s actinic granuloma. Br J Dermatol 1985;113: 353-58.

“Actinic granuloma is a rare granulomatous disease following actinic elastosis. This distinct pathological entity is thought to be a cell-mediated immune reaction to damaged elastotic fibres, but of course this point of view is still a matter of dispute.”
Starz H, Hundhammer K, Pleier R, et al. Actinic granuloma, a rare disease within the spectrum of granulomatous skin reactions. Am J Dermatopathol 1992;14(Abstract):68.

“This [actinic granuloma] is an annular inflammatory reaction with a giant cell dermal infiltrate which develops in an area of actinic elastosis.”
Burton JL. Disorders of connective tissue. In: Champion RH, Burton JL, Ebling FJG, eds. Textbook of Dermatology. 5th ed. Oxford, England: Blackwell Scientific Publications, 1992:1788.

“Annular elastolytic giant cell granuloma and actinic granuloma are unified by their histopathologic appearance. It is currently unclear whether they simply represent variants of granuloma annulare occurring on sun-damaged skin or are distinct diseases”.
Odom RB, James WD, Berger TG. Macrophage/monocyte disorders. In: Odom RB, James WD, Berger TG, eds. Andrews’ Diseases of the Skin, 9th ed. Philadelphia: W. B. Saunders Company, 2000:896.

“Actinic granuloma (AG) and annular elastolytic giant cell granuloma (AEGCG) are terms commonly applied to cutaneous lesions characterized by elastolysis, elastophagocytosis and a multinucleated cell infiltrate…The tissue changes of AG and AEGCG are identical and differ substantially from granuloma annulare because of the predominant elastolysis and elastophagocytosis in the absence of necrobiosis and palisading granuloma.”
Limas C. The spectrum of primary cutaneous elastolytic granulomas and their distinction from granuloma annulare: a clinicopathological analysis. Histopathology 2004; 44: 277-82.

“The condition [actinic granuloma] must be distinguished from granuloma multiforme, granuloma annulare, serpiginous perforating elastosis, Miescher’s disciform granuloma, sarcoidosis and necrobiosis lipoidica. The lesions of actinic granuloma are confined to light-exposed skin, and the infiltrate lacks the tidy palisaded arrangement that is normally seen with granuloma annulare. Rarely, granuloma annulare can occur in an actinic distribution.”
Burrows NP, Lovell CR. Disorders of connective tissue. In: Burns T, Breathnach S, Cox N, et al., eds. Rook’s Textbook of Dermatology, 7th ed. Oxford: Blackwell Science, 2004:46.29.

Annular elastolytic giant-cell granuloma is the name that is currently in vogue for a condition with unclear nosologic status, and it is uncertain whether or not it is truly distinct from granuloma annulare. It almost always occurs on sun-exposed skin, such as the face, neck, dorsum of hand, forearm, and arm; hence the previous name actinic granuloma.”
Glusac EJ, Shapiro PE. Noninfectious granulomas. In: Elder DE, Elenitsas R, Johnson BL, et al., eds. Lever’s Histopathology of the Skin, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2005:376.

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