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Actinic granuloma successfully treated with low-dose doxycycline


1 Department of Dermatology, Chang Gung Memorial Hospital, kou, Taoyuan, Taiwan
2 Department of Dermatology, Chang Gung Memorial Hospital, kou; College of Medicine, Chang Gung University, Taoyuan, Taiwan
3 Department of Dermatology, Chang Gung Memorial Hospital, kou; College of Medicine, Chang Gung University; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan; Graduate Institute of Immunology, College of Medicine, National Taiwan University, Taipei City, Taiwan

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Date of Submission11-May-2021
Date of Decision05-Jun-2021
Date of Acceptance09-Jun-2021
Date of Web Publication19-Jul-2021
 


How to cite this URL:
Huang CH, Chi CC, Chen WT. Actinic granuloma successfully treated with low-dose doxycycline. Dermatol Sin [Epub ahead of print] [cited 2021 Sep 16]. Available from: https://www.dermsinica.org/preprintarticle.asp?id=321878




Dear Editor,

A 76-year-old male farmer presented to our outpatient department with generalized progressive pruritic ring-shaped rashes on the trunk and upper limbs for years. He had type 2 diabetes mellitus, hypertension, hyperlipidemia, and hepatitis B virus infection under control with entecavir. Skin examination showed multiple polycyclic infiltrated plaques with central atrophy and raised erythematous rims on the neck, chest, and back, then spreading to the abdomen and upper limbs [Figure 1]a and [Figure 1]b. All involved skin lesions were distributed in the sun-exposed area because he did not use to wearing garment while working.
Figure 1: Clinical manifestations and histopathology findings of actinic granuloma (a and b) Multiple polycyclic infiltrated plaques with central atrophy and raised erythematous rims on the neck, chest, and back, then spreading to the abdomen and upper limbs. (c) Hematoxylin and eosin-stained and Verhoeff van Gieson-stained section revealed numerous histiocytes arranged interstitially between collagen bundles with scattered multinucleated giant cells engulfing elastic fibers. (d) The skin lesions exacerbated after oral hydroxychloroquine and topical clobetasol ointment.

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A skin biopsy was performed and histopathology specimens showed solar elastosis and numerous histiocytes arranged interstitially between collagen bundles with scattered multinucleated giant cells. Elastic fibers adjacent to or within the giant cells are noted. Verhoeff van Gieson-stained sections revealed fragments of elastin within the giant cells [Figure 1]c. Actinic granuloma was diagnosed. Initially, the patient was treated with intralesional corticosteroid injection, topical application of clobetasol ointment, and then 3.5-month oral hydroxychloroquine with the dose of 400 mg/day. However, the skin lesions exacerbated and expanded centrifugally with central atrophy [Figure 1]d. Low-dose doxycycline 100 mg/day was prescribed alternatively in concern of liver toxicity. After 2-month treatment, the skin lesions became flattened and less pruritic, and there were no new lesions developed in the following 2 months [Figure 2]a and [Figure 2]b.
Figure 2: After 2-month treatment with low-dose doxycycline, the skin lesions became flattened and less pruritic (a and b).

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Actinic granuloma, also called O'Brien's granuloma, is a granulomatous inflammation related to actinically damaged elastic fibers.[1] It is a different entity from granuloma annulare, characterized by asymptomatic, well-defined, erythematous annular plaques with raised border and central atrophy on sun-exposed area. Histologically, actinic granuloma is recognized by giant cells containing elastotic fibers and marked granulomatous reaction in the elastotic dermis without necrobiosis, lipid, mucin, and palisading of the granuloma.[2] Sun protection is important to prevent new lesions. Treatments for actinic granuloma including intralesional steroid injection, ablative laser, hydroxychloroquine, cyclosporine, pentoxifylline, isotretinoin, and acitretin have been reported.[3],[4]

Recently, a case of refractory actinic granuloma successfully treated by doxycycline was reported.[5] Our case had been treated with both topical and intralesional corticosteroid, and hydroxychloroquine initially, but the response was limited. Symptoms improved dramatically after doxycycline was added. Although the exact mechanism in treating actinic granuloma is unknown, doxycycline probably reduces the levels of inflammatory cytokines, including interleukin (IL)-1β, IL-6, and tumor necrosis factor, with resultant inhibition of granulomatous inflammation in actinic granuloma.[6]

In conclusion, doxycycline may be an alternative treatment of actinic granuloma. Further trials are needed to establish the indications and efficacy of treatment.

Ethical approval

This study was approved by the institutional review board of Chang Gung Memorial Hospital (approval number: 202100604B0; approval date: 2021.05.04). The patient consent was waived by the IRB.

Financial support and sponsorship

Nil.

Conflicts of interest

Prof. Ching-Chi Chi, an editorial board member at Dermatologica Sinica, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.



 
  References Top

1.
O'Brien JP, Regan W. Actinically degenerate elastic tissue is the likely antigenic basis of actinic granuloma of the skin and of temporal arteritis. J Am Acad Dermatol 1999;40:214-22.  Back to cited text no. 1
    
2.
McGrae JD Jr. Actinic granuloma. A clinical, histopathologic, and immunocytochemical study. Arch Dermatol 1986;122:43-7.  Back to cited text no. 2
    
3.
Mamalis A, Ho D, Parsi KK, Jagdeo J. Successful treatment of actinic granuloma with pulsed-dye laser and fractionated carbon dioxide laser. Dermatol Surg 2018;44:452-4.  Back to cited text no. 3
    
4.
Rubio FA, Robayna G, Pizarro A, de Lucas R, Herranz P, Casado M. Actinic granuloma and vitiligo treated with pentoxifylline. Int J Dermatol 1998;37:958-60.  Back to cited text no. 4
    
5.
Jeha GM, Luckett KO, Kole L. Actinic granuloma responding to doxycycline. JAAD Case Rep 2020;6:1132-4.  Back to cited text no. 5
    
6.
Henehan M, Montuno M, De Benedetto A. Doxycycline as an anti-inflammatory agent: Updates in dermatology. J Eur Acad Dermatol Venereol 2017;31:1800-8.  Back to cited text no. 6
    

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Correspondence Address:
Wei-Ti Chen,
Department of Dermatology, Chang Gung Memorial Hospital, Linkou 5, Fuxing St., Guishan, Taoyuan 33305
Taiwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.ds_28_21



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