[Granulomatous periocular eruption]

Area of Science:

• Dermatology
• Pathology
• Immunology

Background:

• A case of atypical periorificial dermatitis is presented in a patient with a history of atopic dermatitis.
• The rash exhibited a unique periocular predominance without perioral involvement, presenting with a clinical and histological picture suggestive of sarcoidosis.

Observation:

• A 33-year-old male with facial atopic dermatitis, poorly responsive to topical corticosteroids, was treated with topical tacrolimus 0.1%.
• After prolonged tacrolimus use, symmetric erythematous, micropapular lesions with edema developed on the eyelids and periorbital regions.
• Histopathology revealed epithelioid granulomatous inflammation with sarcoidal giant-cell features, but staging tests for systemic sarcoidosis were negative.

Findings:

• The patient was diagnosed with granulomatous periorificial dermatitis, despite the rare exclusively periorbital involvement.
• Alternative diagnoses considered included pure cutaneous sarcoidosis and tacrolimus-induced granulomatous rosacea, but these were less consistent with the clinical and histological findings.
• Complete remission was achieved within two months by discontinuing topical tacrolimus and initiating hydroxychloroquine 400mg daily.

Implications:

• This case highlights that a histological sarcoidosis-like appearance on skin biopsy can be associated with perioral dermatitis.
• The findings suggest a potential link between topical calcineurin inhibitors like tacrolimus and the development of granulomatous facial dermatoses.
• Successful management with hydroxychloroquine offers a therapeutic option for similar challenging cases.