Palisade neutrophilic and granulomatous dermatitisL95.1

Rare, chronic reactive, papular or plaque-type extremity dermatitis, which is considered a skin disease commonly associated with rheumatoid arthritis. However, palisade-shaped neutrophil and granulomatous dermatitis also occurs in the wake of other systemic diseases(systemic lupus erythematosus, sarcoidosis, Behçet's disease, spondylarthritis, borreliosis and lymphoproliferative diseases). Furthermore, it is used as a UAW in various diseases. It is also described as an adverse drug reaction.

Very rare. Individual case descriptions. No gender accentuation

Middle to advanced age; rarely childhood.

Palms, back of the hand, fingers, elbows, more rarely lower extremity, face or capillitium.

Blurred, asymptomatic, mostly disseminated, chronically persistent red-livid papules and plaques; more rarely nodules.

Nodular infiltrates of lymphocytes, macrophages, eosinophilic and neutrophilic granulocytes are found throughout the dermis, extending to the border of the subcutis; often accompanied by nuclear dust as a sign of leukocytoclasia. Only isolated multinuclear giant cells. The infiltrates are often grouped around flat degenerated collagen. Furthermore, small and medium-sized vessels with fibrinoid swollen vessel walls are frequently detected.

Erythema elevatum diutinum, interstitial granulomatous dermatitis, granulomatosis disciformis chronica et progressiva

Treatment of the underlying disease

The terms "palisaded neutrophilic and granulomatous dermatitis," "interstitial granulomatous dermatitis," and "interstitial granulomatous drug reaction," the possible clinical and histological overlap of the disease patterns cause significant differential diagnostic problems. The reports are generally based on individual case descriptions. The assumption is an unspecific "reaction cutanèe" to an underlying systemic disease or cofactorially to an additional therapy regime. To what extent these are "entities" may be doubted, particularly since a comparative evaluation of the older literature (for example the erythema elevatum diutinum or the granulomatosis disciformis et progressiva which also belong to the group of reactive granulomatous dermatitis) is missing. Rosenbach et al. recommend the non-evaluative summary diagnosis for this group of diseases:"reactive granulomatous dermatitis".

The 73-year-old patient, who has been suffering from rheumatoid arthritis for about 5 years. She has been treated for years with methotrexate (15mg/week s.c.) and adalimumab. Otherwise occasionally non-steroidal anti-inflammatory drugs. Skin changes resistant to treatment have existed on both hands for years

Clinically, multiple, disseminated red-livid, asymptomatic surface-smooth papule plaques were found in a symmetrical arrangement on palmar as well as on both backs of the hands (here reinforced above the metacarpophalangeal joints). The plaques were up to 2.0 cm in size.

Laboratory: rheumatoid factor: within normal range; anti-CCP-AK: moderately elevated. Inflammation parameters significantly increased.

1. Biswas A et al(2008) Palisaded neutrophilic and granulomatous dermatitis in a child with type I diabetes mellitus and coeliac disease. Br J Dermatol 159:488-489.
2. de Unamuno Bustos B et al.(2013) Palisaded neutrophilic and granulomatous dermatitis associated with ankylosing spondylitis At J Dermatopathol 35:847-850.
3. Gordon K et al (2012) Allopurinol-induced palisaded neutrophilic and granulomatous dermatitis. Cutan ocul toxicol 31:338-340.
4. Gulati A et al (2009) Palisaded neutrophilic granulomatous dermatitis associated with systemic lupus erythematosus presenting with the burning rope sign. J Am Acad Dermatol 61:711-714.
5. Hunt RD et al (2012) Palisaded neutrophilic and granulomatous dermatitis in an adolescent girl with perinuclear antineutrophil cytoplasmic antibody-positive pauci-immune glomerulonephritis and arthritis. J Am Acad Dermatol 67:e164-166.
6. Kim SK et al, (2005) Palisaded neutrophilic granulomatous dermatitis presenting as an unusual skin manifestation in a patient with Behçet's disease. Scand J rheumatol 34:324-327.
7. Misago N et al, (2011) Palisaded neutrophilic granulomatous dermatitis caused by cellulitis in a patient with systemic lupus erythematosus. Int J Dermatol 50:1583-1585.
8. Muscardin LM et al(2007) Erythema elevatum diutinum in the spectrum of palisaded neutrophilic granulomatous dermatitis: description of a case with rheumatoid arthritis. J Eur Acad Dermatol Venereol 21:104-105.
9. Nguyen TA et al (2016) Palisaded Neutrophilic Granulomatous Dermatitis in a Child with Juvenile Idiopathic Arthritis on Etanercept. Pediatric Dermatol 33:e156-157.
10. Paštar Z et al (201) Palisaded neutrophilic and granulomatous dermatitis in association with subcutaneous nodular and systemic sarcoidosis. Acta dermatovenerol Croat 21:245-249.
11. Pirowska M et al (2016) Palisaded neutrophilic and granulomatous dermatitis - cutaneous manifestation of Lyme disease or connected with CTD? Case report. Ann Agric Environ Med 23:384-386.
12. Stephenson SR et al (2011) Palisaded neutrophilic and granulomatous dermatitis presenting in a patient with rheumatoid arthritis on adalimumab. J Cutan catheter 38:644-648.
13. Rosenbach M et al (2015) Reactive Granulomatous Dermatitis: A Review of Palisaded Neutrophilic and Granulomatous Dermatitis, Interstitial Granulomatous Dermatitis, Interstitial Granulomatous Drug Reaction, and a Proposed Reclassification. Dermatol Clin 33:373-387.
14. Umezawa Y et al(2013) Palisaded neutrophilic and granulomatous dermatitis in a rheumatoid arthritis patient after treatment with adalimumab. Eur J Dermatol 23:910-911.