10.5826/dpc.1303a129
Introduction: Reactive granulomatous dermatitis (RGD) is a new entity, which is highly associated with systemic disorders. There is scarce data regarding interstitial granulomatous dermatitis (IGD) and palisaded neutrophilic granulomatous dermatitis (PNGD).
Objectives: We aimed to evaluate clinical and histopathological characteristics of IGD and PNGD as unified entities under the term of RGD.
Methods: Observational, retrospective, single-center study of patients diagnosed with IGD and PNGD between 2012 and 2021 were included in the study.
Results: Of 16 patients with RGD 13 had IGD and 3 had PNGD (14 females, 2 males) with a mean age of 62,5. The most common presentation was plaques 37,5% (n=6), followed by patches 25%. The most common localization of involvement was lower extremity 75%, followed by trunk and upper extremity. Multiple localization of involvement was determined in 75% of patients. None of the patients had rope sign. Associated comorbidities such as autoimmune diseases and malignancies were detected in 68,7% of patients. In majority of biopsies (85,7%), there were lymphohistiocytic cell infiltration. Other accompanying cells were scarce neutrophils 31,2% and eosinophils 31,2%. All of the biopsies had interstitially located lymphohistiocytic cell infiltration surrounding with swollen and degenerated collagen. Palisaded pattern was determined in 18,7% of patients and floating sign was seen in 18,7% of biopsies.
Conclusions: RGD is a rare entity and most patients with RGD had associated disorders such as autoimmunity or malignancy. There is overlapping between IGD and PNGD, therefore supporting the usage of umbrella term as reactive granulomatous dermatitis is compatible with the literature.
text/xml
2160-9381
2841
en
Cem Leblebici
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Reactive granulomatous dermatitis
Interstitial Granulomatous Dermatitis and Palisaded Neutrophilic Granulomatous Dermatitis: Retrospective Clinicopathological Analysis of 16 cases
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-09-13
2023-07-31
2023-08-24
e2023129
Dermatol Pract Concept
Introduction: Reactive granulomatous dermatitis (RGD) is a new entity, which is highly associated with systemic disorders. There is scarce data regarding interstitial granulomatous dermatitis (IGD) and palisaded neutrophilic granulomatous dermatitis (PNGD).
Objectives: We aimed to evaluate clinical and histopathological characteristics of IGD and PNGD as unified entities under the term of RGD.
Methods: Observational, retrospective, single-center study of patients diagnosed with IGD and PNGD between 2012 and 2021 were included in the study.
Results: Of 16 patients with RGD 13 had IGD and 3 had PNGD (14 females, 2 males) with a mean age of 62,5. The most common presentation was plaques 37,5% (n=6), followed by patches 25%. The most common localization of involvement was lower extremity 75%, followed by trunk and upper extremity. Multiple localization of involvement was determined in 75% of patients. None of the patients had rope sign. Associated comorbidities such as autoimmune diseases and malignancies were detected in 68,7% of patients. In majority of biopsies (85,7%), there were lymphohistiocytic cell infiltration. Other accompanying cells were scarce neutrophils 31,2% and eosinophils 31,2%. All of the biopsies had interstitially located lymphohistiocytic cell infiltration surrounding with swollen and degenerated collagen. Palisaded pattern was determined in 18,7% of patients and floating sign was seen in 18,7% of biopsies.
Conclusions: RGD is a rare entity and most patients with RGD had associated disorders such as autoimmunity or malignancy. There is overlapping between IGD and PNGD, therefore supporting the usage of umbrella term as reactive granulomatous dermatitis is compatible with the literature.
Cem Leblebici
2023/07/31
10.5826/dpc.1303a129
e2023129
Department of Pathology, University of Health Science (HSU) Istanbul Training and Research Hospital, Istanbul, Turkey
2160-9381
Reactive granulomatous dermatitis
en
e2023129
Shin YB, Jo JW, Yoon TJ. Palisaded Neutrophilic and Granulomatous Dermatitis in a Patient with Behçet's Disease: A Case Report. Ann Dermatol. 2021;33(1):73-76. DOI:10.5021/ad.2021.33.1.73. PMID: 33911815..
Interstitial Granulomatous Dermatitis and Palisaded Neutrophilic Granulomatous Dermatitis: Retrospective Clinicopathological Analysis of 16 cases
https://dpcj.org/index.php/dpc/article/download/2841/2208
       Interstitial Granulomatous Dermatitis and
  Palisaded Neutrophilic Granulomatous Dermatitis:
      Retrospective Clinicopathological Analysis
                       of 16 Cases
     Ebru Sarıkaya Tellal1, Dilara Ilhan Erdil1, Muge Gore Karaali2, Ayse Esra Koku Aksu1,
                       Erdemir VA3, Asude Kara Polat1, Cem Leblebici4


1 Department of Dermatology, University of Health Science (HSU) Istanbul Training and Research Hospital, Istanbul, Turkey
2 Department of Dermatology, Irmet International Hospital, Tekirdag, Turkey
3 Department of Dermatology, Göztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey
4 Department of Pathology, University of Health Science (HSU) Istanbul Training and Research Hospital, Istanbul, Turkey



Key words: granulomatous dermatitis, interstitial granulomatous dermatitis, palisaded neutrophilic and granulomatous dermatitis, reactive
granulomatous dermatitis
Citation: Sarıkaya Tellal E, Ilhan Erdil D, Gore Karaali M, et al. Interstitial Granulomatous Dermatitis and Palisaded Neutrophilic
Granulomatous Dermatitis: Retrospective Clinicopathological Analysis of 16 Cases. Dermatol Pract Concept. 2023;13(3):e2023129.
DOI: https://doi.org/10.5826/dpc.1303a129
Accepted: December 1, 2022; Published: July 2023
Copyright: ©2023 Sarıkaya Tellal et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Muge Gore Karaali, MD, Irmet International Hospital, Tekirdag, Turkey. Tel: +9005303093328
E-mail: mugegore@hotmail.com




  ABSTRACT             Introduction: Reactive granulomatous dermatitis (RGD) is a new entity, which is highly associated
                       with systemic disorders. There is scarce data regarding interstitial granulomatous dermatitis (IGD) and
                       palisaded neutrophilic granulomatous dermatitis (PNGD).
                       Objectives: We aimed to evaluate clinical and histopathological characteristics of IGD and PNGD as
                       unified entities under the term of RGD.
                       Methods: Observational, retrospective, single-center study of patients diagnosed with IGD and PNGD
                       between 2012 and 2021 were included in the study.
                       Results: Of 16 patients (14 females and 2 males) with RGD, 13 had IGD and 3 had PNGD with a
                       mean age of 62.5 years. The most common clinical presentation was plaques 37.5% (N=6), followed
                       by patches 25% (N=4). The most common localization of involvement was lower extremity 75%
                       (N=12), followed by trunk and upper extremity. Multiple localization of involvement was determined
                       in 75% (N=12) of patients. None of the patients had rope sign. Associated comorbidities such as




Original Article | Dermatol Pract Concept. 2023;13(3):e2023129                                                                          1
                      autoimmune diseases and malignancies were detected in 68.7% (N=11) of patients. In majority of
                      biopsies (87.5%; N=14), there were lymphohistiocytic cell infiltration. Other accompanying cells were
                      scarce neutrophils 31.2% (N=5) and eosinophils 31.2% (N=5). All of the biopsies had interstitially
                      located lymphohistiocytic cell infiltration surrounding with swollen and degenerated collagen. Pali-
                      saded pattern was determined in 18.7% (N=3) of patients and floating sign was seen in 18.7% (N=3)
                      of biopsies.
                      Conclusions: RGD is a rare entity and most patients with RGD had associated disorders such as
                      autoimmunity or malignancy. There is overlapping between IGD and PNGD, therefore supporting the
                      usage of umbrella term as reactive granulomatous dermatitis is compatible with the literature.




Introduction                                                        to 25% of patients however, concomitant disease may also
                                                                    occur after the diagnosis and so follow up is required [2,4].
Interstitial granulomatous dermatitis (IGD) and palisaded
neutrophilic granulomatous dermatitis (PNGD) are reactive
granulomatous inflammatory skin disorders which were
                                                                    Objectives
recently proposed to be unified under the term of reactive          To analyze the clinicopathological findings and the disease
granulomatous dermatitis (RGD). They are highly associated          associations of RGD.
with systemic disorders with only few and recent large pa-
tient population studies regarding the concept of RGD [1,2].
    IGD and PNGD are uncommon clinicopathological en-               Methods
tities with a wide spectrum of clinical manifestations, and
                                                                    We conducted an observational, retrospective study for clin-
also it can be difficult to establish clinical and pathological
                                                                    ical and histopathological analysis of 16 patients diagnosed
correlations of these diseases. IGD usually presents with er-
                                                                    with IGD and PNGD between the years 2012 and 2021 by
ythematous to violaceous patches or plaques symmetrically
                                                                    searching the database of the Pathology and Dermatology
located on the upper trunk or proximal limbs, and PNGD
                                                                    Departments of a tertiary center. The study has been ap-
with plaques/papules/nodules sometimes painful with cen-
                                                                    proved by the Institutional Review Board of the hospital.
tral ulceration or crust distributed on the extensor limbs
                                                                       Previously defined histopathological criteria, including
[3,4]. Despite of initial reporting of classical presentation of
                                                                    presence of histiocytic and lymphocytic infiltration through
IGD with rope sign (linear subcutaneous cords), it is seen
                                                                    the dermis and surrounding with foci of degenerated col-
rarely in the current reports [2].
                                                                    lagen was used in the current study [2]. The presence of a
    Histopathologically a diffuse, interstitial and perivascu-
                                                                    “floating sign” was noted, which is the visible clefting in ab-
lar, superficial and deep inflammatory infiltrate composed
                                                                    normal collagen by the clusters of histiocytes. Mucin depos-
mainly of lymphocytes and histiocytes surrounding foci of
                                                                    its should be absent or moderate. Patients who did not meet
collagen degeneration in the dermis with a limited number of
                                                                    these criteria, and who had alternative diagnosis (necrobio-
neutrophils and eosinophils have been determined. Scarce in-
                                                                    sis lipoidica, granuloma annulare, interstitial granulomatous
terstitial mucin deposition can be present. IGD usually does
                                                                    drug reaction) were excluded from the study.
not have leukocytoclastic vasculitis (LV). On the other hand,
                                                                       For clinical analysis, sex, age at the diagnosis, local-
despite overlapping histopathological findings with IGD,
                                                                    ization, characteristics of the cutaneous lesions, associated
PNGD biopsies are characterized by more intense neutro-
                                                                    symptoms, medical comorbidities, medication use, labora-
philic infiltration, karyorrhexis, more degenerated collagen
                                                                    tory values and treatments were recorded.
in dermis, palisading granuloma with or without LV com-
pared with IGD. Interstitial granulomatous drug reaction is
also a form of IGD can mimic PNGD and IGD both clini-               Results
cally and histologically with prominent eosinophilic infiltra-
tion [2].                                                           Clinical Findings
    Associated comorbidities of RGD include autoimmune              This study included 16 patients (14 females; 2 males, fe-
diseases (as the most common cause), malignancy and in-             male:male ratio of 7:1) aged between 42 and 81 years (mean
fections. It is reported in the literature that there are not any   62.5±11.1 years). Symptom duration ranged from 1 month
associated comorbidities at the time of the diagnose in up          to 30 months (mean 7.0 ± 8.3 months). The most common



2                                                                       Original Article | Dermatol Pract Concept. 2023;13(3):e2023129
presentation was isolated plaques 37.5%, followed by only             in 18.7% of patients and C-ANCA was positive in a single
patch 25%, papules and plaques in 12.5% patients, one                 patient. During the follow-up, one of the patients diagnosed
patient with papule and one patient with macule, papule,              with Sjogren syndrome and the other patient with history of
purpura. “Rope sign” was not present in any of the patients.          thyroiditis was diagnosed with rheumatoid arthritis.
All lesions were violaceous and/or erythematous in color                  Patients with RGD were treated with topical corticoste-
(Figure 1). Most common localization was lower extrem-                roids and also underlying systemic diseases were treated. All
ity (mainly medial thigh region) 75%, followed by trunk               the lesions resolved completely with topical therapy in about
50%, upper extremity 43.7%. Multiple site involvement                 six months without recurrency in a mean of 39.8 month fol-
was seen in 75% of patients. One patient had face and neck            low up. The clinical features of the 16 patients are summa-
involvement.                                                          rized in Table 1.
    Mycosis fungoides (56.2%) was the most commonly dif-
ferential diagnosis of IGD/PNGD. IGD/PNGD were among                  Histopathological Findings
the pathological pre-diagnoses in only 25% of the patients.           Epidermis was preserved in 82.7% of the biopsies. Others
Associated autoimmune systemic disease or malignancy                  had hyperkeratosis, parakeratosis, acanthosis and mild in-
was observed in 12 patients (68.7%). Associated diseases of           creased pigmentation. In all biopsies, there were lympho-
PNGD were autoimmune hepatitis in one patient, Sjögren                histiocytic cell infiltration. Other accompanying cells were
syndrome in one patient, lung cancer and Churg Strauss                scarce neutrophils (31.2%), eosinophils (31.2%) and plas-
syndrome in one patient. In a single patient IGD occurred             mocytes (12.5%). All of the biopsies had interstitially lo-
as Wolf isotopic response after herpes zoster (Patient #13).          cated lymphohistiocytic cell infiltration surrounding with
Comorbidities of patients with IGD and PNGD were listed               swollen and degenerated collagen. Palisaded pattern with
in Table 1. The drugs used by the patients for their associated       combination of interstitial pattern was observed in 18.7%
diseases were listed in Table 1. All of these drugs were used         of patients. Floating sign was detected in 18.7% of biop-
by the patients for many years.                                       sies. None of the biopsies had dermal fibrosis. Alcian blue
    In 31.2% of patients there were no associated disease             staining demonstrated interstitial minimal mucin in 56%
despite of clinical and laboratory evaluation for an under-           of the biopsies and moderate mucin in one case, remaining
lying disorder; 12.5% of patients, had both ANA positivity            biopsies did not reveal mucin formation. Nuclear debris
and arthralgia. Rheumatoid factor (RF) positivity was seen            was seen in 31.2%, vasculitic changes such as fibrinoid




   Figure 1. Some clinical presentations of the patients. (A) Erythematous papules and plaques on the anterolateral abdomen. (B) Vio-
   laceous papules extending from inframammary region to lateral trunk. (C) Violaceous macules on the arm. (D) Violaceous plaque on
   the inner thigh.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023129                                                                          3
 Table 1. Clinical features of 16 patients diagnosed with interstitial granulomatous dermatitis (IGD)
                    and palisaded neutrophilic granulomatous dermatitis (PNGD).
 Patient
                   Age       Time to Lesion                    Localization           Associated Diseases/Drugs          Final
 Nr.        Sex    (year)    Lesion Characteristics             of Lesions            (if available)                     diagnosis
 1          F      77        2 mo       Erythematous           Trunk, lower           Hypertension                       IGD
                                        plaques                extremity              (calcium channel blockers)
 2          F      42        2 mo       Violaceous papules Upper extremity            Rheumatoid arthritis               IGD
                                        and plaques                                   (non-steroid anti-
                                                                                      inflammatory drugs)
 3          F      58        1,5 mo     Erythematous to        Face,neck, upper       Autoimmune hepatitis               PNGD
                                        violaceous papules     extremity              (azathioprine)
                                        and plaques
 4          F      66        9 mo       Violaceous plaques Trunk, lower               Hypertension                       IGD
                                                           extremity                  (thiazide diuretic+
                                                                                      angiotensin receptor blocker)
 5          F      58        4 mo       Erythematous to        Upper extremity,       Thyroiditis, type 2 diabetes       IGD
                                        violaceous plaques     lower extremity        mellitus
                                                                                      (levothyroxine)
 6          F      58        24 mo      Violaceous             Lower extremity        Sjögren syndrome                   PNGD
                                        macules, papules
                                        and petechies
 7          F      58        6 mo       Violaceous plaques Upper extremity,           Tubulovillous adenoma with         IGD
                                                           trunk, lower               high dysplasia
                                                           extremity
 8          F      81        12 mo      Erythematous           Upper and lower        Thyroiditis                        IGD
                                        plaques                extremity              (levothyroxine)
 9          F      71        3 mo       Erythematous           Trunk, lower           Hypertension                       IGD
                                        patches                extremity              (thiazide diuretic+
                                                                                      angiotensin receptor blocker)
 10         F      68        2 mo       Violaceous patches     Lower extremity        Hypertension                       IGD
                                                                                      (angiotensin-receptor
                                                                                      blocker)
 11         M      44        3 mo       Erythematous           Upper extremity,       Rheumatoid arthritis               IGD
                                        plaques                trunk                  (colchicine)
 12         F      58        30 mo      Erythematous           Trunk, lower           Behçet disease                     IGD
                                        patches                extremity              (colchicine)
 13         F      69        1 mo       Violaceous papules Trunk                      Rheumatoid arthritis               IGD
 14         F      50        6 mo       Erythematous           Trunk, lower           None                               IGD
                                        patches                extremity
 15         M      71        1 mo       Erythematous           Upper and lower        Lung adenocarcinoma,               PNGD
                                        patches, plaques       extremity              Churg Strauss syndrome
                                        and nodules
 16         F      71        6 mo       Erythematous           Trunk, lower           Thyroiditis, hypertension          IGD
                                        plaques and            extremity              (levothyroxine, thiazide
                                        patches                                       diuretic)

IGD = interstitial granulomatous dermatitis; mo = months; PNGD = palisaded neutrophilic granulomatous dermatitis.




necrosis was seen in 12.5%, leukocytoclasis in 12.5% of             Conclusions
patients. Leukocytoclastic vasculitis was determined in
12.5% of patients. Histopathological information of the             RGD is an umbrella term for IGD and PNGD, which are
16 biopsies is summarized in table 2 and some examples              rarely seen dermatosis with a wide clinical spectrum. IGD
are shown in Figure 2.                                              and PNGD have overlapping clinical and histopathological



4                                                                        Original Article | Dermatol Pract Concept. 2023;13(3):e2023129
                                                                              Table 2. Histopathological features of 16 patients diagnosed with interstitial granulomatous dermatitis and palisaded neutrophilic
                                                                                                                                   granulomatous dermatitis.
                                                                                 Epidermal        Lymphohistiocytic        Floating                  Palisading   Fibrinoid                                  Nuclear
                                                                  Patient      involvement          cell infiltration        sign          Mucin      Pattern     necrosis    Vasculitis   Leukocytoclasia   Debris    Neutrophil   Eosinophil
                                                                  1                   +                    +                    -         minimal        -            -           -               -             -          -            -
                                                                  2                   -                    +                    -         minimal        -            -           -               -            +           +            +
                                                                  3a                  +                    +                    -              -         +            -           -               -            +           +            +
                                                                  4                   -                    +                   +          minimal        -            -           -               -             -          -            -




Original Article | Dermatol Pract Concept. 2023;13(3):e2023129
                                                                  5                   -                    +                   +               -         -            -           -               -             -          -            +
                                                                   a
                                                                  6                   -                    +                    -              -         +            -           -               -            +           -            -
                                                                  7                   -                    +                    -         minimal        -            -           -               -             -          -            -
                                                                  8                   -                    +                    -         minimal        -            -           -               -             -          -            -
                                                                  9                   -                    +                    -              -         -            -           -               -             -          -            -
                                                                  10                  -                    +                    -         moderate       -            -           -               -             -          -            -
                                                                  11                  -                    +                    -         minimal        -           +            +              +             +           +            +
                                                                  12                  -                    +                   +               -         -            -           -               -             -          +            -
                                                                  13                  -                    +                    -              -         -            -           -               -             -          -            -
                                                                  14                  -                    +                    -         minimal        -            -           -               -             -          -            -
                                                                       a
                                                                  15                  +                    +                    -         minimal        +           +            +               -            +           +            -
                                                                  16                  -                    +                    -         minimal        -            -           -               -             -          -            +

                                                                 PNGD = palisaded neutrophilic granulomatous Dermatitis.aPatients with PNGD.




5
    Figure 2. Some histopathological examination of the skin of patients. (A) Interstitial lymphohistiocytic infiltrate with collagen
    degeneration- interstitial granulomatous dermatitis subtype (H&E, ×100). (B) Collagen degeneration and “floating sign” with lym-
    phohistiocytic infiltrate (H&E, ×200). (C) Palisading granulomas accompanied by neutrophils, lymphohistiocytic infiltration, collagen
    degeneration (H&E, ×200). (D) Palisading granulomas accompanied by neutrophils, lymphohistiocytic infiltration, collagen degen-
    eration (H&E, ×400).




findings. Therefore, more extensive reports on these diseases           and/or malignancy (lung adenocarcinoma) were accompa-
are needed.                                                             nied in all (100.0%) PNGD patients, in 7 of 13 (53.8%)
    Reported clinical presentations of RGD in the previous              patients with IGD had autoimmunity and 1 (7.7%) had
studies are annular plaques, erythematous-violaceous pap-               malignancy (tubulovillous adenoma with high dysplasia).
ules or nodules [4,5], non-scaly annular plaques (similar to            Neutrophilic infiltration was determined in all patients with
most of our patients) [4,6,7], linear-shaped plaques [8,9] and          palisading pattern and all of them were associated with auto-
arciform-non scaly nodules [10]. Most of our patients pre-              immunity or malignancy. However, we could not detect any
sented with MF like, erythematous to violaceous plaques on              clinical and/or histopathological data that can definitely dis-
the sun-protected sites such as axilla, lateral chest or inner          tinguish between these two entities due to a small number of
thighs. Since RGD is a rare disease, this diagnosis can be un-          PNGD patients and overlapping features of IGD and PNGD.
derestimated by clinicians, thus in only 25% of the patients            For this reason, the term proposed as RGD in the current
in our study, pre-diagnosis of IGD/PNGD was possible due                studies will be appropriate.
to a wide spectrum of presentations. According to our results               Comorbidities associated with our patients were similar
RGD should be considered in the differential diagnosis of               to the literature (60-76%) [1,2,4]. In one 69-year-old female
plaque lesions on sun-protected areas. It has been reported             patient with a history of herpes zoster, IGD developed in the
that the rope sign is rarely seen in studies, similar to these          same localization after one month. We evaluated this patient
studies, this finding was not found in any of the patients in           as Wolf’s isotopic response. One patient with Wolf isotopic
our study, despite of initial reporting of classical presentation       response was reported in the literature. This patient was
of IGD with rope sign [2].                                              an 11-year-old boy diagnosed with IGD possibly to herpes
    Due to possible accompanying diseases, correct and early            zoster [11]. Autoimmune hepatitis associated with IGD was
diagnosis of RGD is important. In our study, autoimmunity               previously reported [3,12,13]. In our series, the patient with




6                                                                            Original Article | Dermatol Pract Concept. 2023;13(3):e2023129
PNGD was accompanied by autoimmune hepatitis. In liter-                      palisaded neutrophilic and granulomatous dermatitis: a study of
ature, other diseases which may accompany were autoim-                       52 patients. J Eur Acad Dermatol Venereol. 2021;35(4):988-994.
                                                                             DOI: 10.1111/jdv.17010. PMID: 33098595.
mune disorders such as; rheumatoid arthritis [3,4], systemic
                                                                        3.   Rosenbach M, English JC 3rd. Reactive Granulomatous Derma-
lupus erythematosus [1,3,4,16], autoimmune thyroiditis,
                                                                             titis: A Review of Palisaded Neutrophilic and Granulomatous
primary biliary cirrhosis [7], malignancies such as hema-                    Dermatitis, Interstitial Granulomatous Dermatitis, Interstitial
tological or solid cancers [14,15], infections such as HCV                   Granulomatous Drug Reaction, and a Proposed Reclassifi-
and related cryoglobulinemia [10], coccidiomycosis [17]                      cation. Dermatol Clin. 2015;33(3):373-387. DOI: 10.1016/j
or medications [4,5]. In 31.2% of patients, there were no                    .det.2015.03.005. PMID: 26143420.
                                                                        4.   Coutinho I, Pereira N, Gouveia M, Cardoso JC, Tellechea O.
associated autoimmunity or malignancy despite of clinical
                                                                             Interstitial Granulomatous Dermatitis: A Clinicopathologi-
and laboratory evaluation for an underlying disorder. Due
                                                                             cal Study. Am J Dermatopathol. 2015;37(8):614-619. DOI:
to high association with systemic disorders, follow-up of                    10.1097/DAD.0000000000000288. PMID: 25830722.
the patient for the possible development of autoimmunity                5.   Veronez IS, Dantas FL, Valente NY, Kakizaki P, Yasuda TH,
or malignancy is important despite of having no associated                   Cunha Tdo A. Interstitial granulomatous dermatitis: rare cuta-
features at time of diagnosis.                                               neous manifestation of rheumatoid arthritis. An Bras Dermatol.
                                                                             2015;90(3):391-393. DOI: 10.1590/abd1806-4841.20153263.
    In addition to reported comorbidities, we had a patient
                                                                             PMID: 26131871. PMCID: PMC4516102.
with Behçet disease and IGD in our case series. When we
                                                                        6.   Altemir A, Iglesias-Sancho M, Sola-Casas MLÁ, Novoa-Lamazares L,
search for the literature, Behçet’s disease accompanies only                 Fernández-Figueras M, Salleras-Redonnet M. Interstitial gran-
two patients with PNGD [18,19]. Kim et al. reported a                        ulomatous dermatitis following tocilizumab, a paradoxical
32-year-old female with papular lesions on legs [18]. Shin                   reaction? Dermatol Ther. 2020;33(6):e14207. DOI: 10.1111
et al. reported a 60-year-old female with also popular lesions               /dth.14207. PMID: 32816393.
                                                                        7. Wang Y, Wu Y, Zheng Z, Bai Y, Cui Y. Interstitial granulomatous
on extremities, buttocks, and ear lobes [19]. In our study
                                                                           dermatitis associated with primary biliary cirrhosis. J Dermatol.
the patient with IGD and Behçet disease was 58-year-old
                                                                           2018;45(1):112-113. DOI: 10.1111/1346-8138.13778. PMID:
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trunk and legs.                                                         8. Kim YS, Lee JH, Lee JY, Park YM. Interstitial Granulomatous
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                                                                           PMID: 27274645. PMCID: PMC4884723.
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                                                                        9. Verneuil L, Dompmartin A, Comoz F, Pasquier CJ, Leroy D.
in methods, interstitial granulomatous drug reaction was
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excluded from the study. However, when the drugs used by                   and arthritis: a disorder associated with autoantibodies.
the patients, especially the antihypertensive drugs were eval-             J Am Acad Dermatol. 2001;45(2):286-291. DOI: 10.1067
uated, they were not considered to be associated with IGD                  /mjd.2001.114577. PMID: 11464193.
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                                                                           ulomatous dermatitis in a patient with chronic hepatitis C and
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    RGD is a rare clinicopathological entity. This is one of
                                                                           qt3x33s9m7. PMID: 29469770.
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Since there is a high association with systemic disorders, fol-            sponse possibly to herpes zoster in childhood. J Dermatol.
low up of patients is required. Due to overlapping features                2014;41(7):651-652.
between IGD and PNGD, the term proposed as RGD in the                  12. Lee KJ, Lee ES, Lee DY, Jang KT. Interstitial granulomatous
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