Eruptive xanthoma: a microscopic simulant of granuloma annulare

The microscopic appearance of eruptive xanthoma (EX) presents the potential for misinterpretation as granuloma annulare (GA). Both exhibit one or multiple lesions in the superficial reticular dermis. Both have a perivascular and interstitial inflammatory cell infiltrate. Extracellular lipid in EX separates and disrupts the reticular dermis, simulating necrobiosis. There are several useful differential diagnostic features. The perivascular infiltrate is histiocytic in EX and lymphoid in GA. The histiocytes of EX have translucent, finely stippled cytoplasm, whereas those of GA have denser eosinophilic cytoplasm. EX lacks a distinctly granulomatous appearance, whereas epithelioid and multinuclear cells are typical of GA. The semilucent extracellular deposits of lipid in EX are associated with only minimal fragmentation of collagen and no evidence of cellular necrosis. Necrobiotic material stains more deeply eosinophilic or basophilic; degradation of collagen is discernable, and there is often evidence of cell death. Both EX and GA exhibit deposits of hyaluronic acid. They tend to be concentrated at the borders of lesions in EX and in the centers of lesions in GA. Elastolysis was not appreciated in EX. It was present in some cases of GA.