Palisaded Granulomatous Dermatitis Associated with Ulcerative Colitis: A Comprehensive Literature Review

Abstract

Palisaded granulomatous dermatitis is an uncommon pathologic condition potentially associated with several disorders. These include drugs, inflammatory bowel disease, multiple myelomas, rheumatoid arthritis, and systemic lupus erythematosus. An illustrative case of a man with palisaded granulomatous dermatitis who subsequently developed ulcerative colitis is described, and the characteristics of other individuals with ulcerative colitis-associated palisaded granulomatous dermatitis are reviewed. PubMed was used to search the following terms: palisaded, interstitial, granulomatous, dermatitis, ulcerative colitis, and neutrophilic. Papers were obtained and references were reviewed. Ulcerative colitis-associated palisaded granulomatous dermatitis is uncommon. Palisaded granulomatous dermatitis-associated ulcerative colitis has been reported in four individuals. The palisaded granulomatous dermatitis appeared from six years prior to diagnosis to 19 years following diagnosis of the patient's gastrointestinal disease. In addition to individual and grouped papular lesions on the elbows, the morphology of palisaded granulomatous dermatitis can also present as indurated linear plaques overlying the metacarpophalangeal (MCP) joints and proximal fingers.

Keywords: dermatitis; granulomatous; palisaded; ulcerative colitis.

Figure 1. Right elbow lesions of palisaded granulomatous dermatitis

Distant (a) and closer (b and c) views of the right elbow show individual and confluent erythematous papules. Some of the papules are arranged in an annular distribution.

Figure 2. Palisaded granulomatous dermatitis involving the hands

Distant (a) and closer (b and c) views of both hands; the right hand (b) and the left hand (c) show nodules overlying the second, third, and fourth metacarpophalangeal (MCP) joints of the right hand and the third, fourth, and fifth MCP joints of the left hand. In addition, the right hand (b) and the left hand (c) show linear plaques extending from the third (right hand) and fourth (left hand) MCP joint towards the proximal interphalangeal (PIP) joint which were morphologically cord-like or rope-like.

Figure 3. Palisaded granulomatous dermatitis lesions blanch when hands are fisted

The lesions are blanched and accentuated when the right (a) and left (b) hand is fisted.

Figure 4. Histology of lesion on the right elbow

Microscopic examination of a skin lesion on the right elbow shows palisaded granulomas that extend into the mid-reticular dermis (a and b). Closer examination (b) shows histiocytes and lymphocytes palisading around area of degenerated collagen. Fibrin deposition is noted in the center of the granulomas (c and d). Mucin is present throughout the dermis; however, it is not increased within the altered collagen surrounded by the granuloma (e and f). (hematoxylin and eosin: x2 = a, x20 = b; periodic acid-Schiff: x4 = c, x40 = d; colloidal iron: x4 = e, x20 = f)

Figure 5. Histology of lesion on right third metacarpophalangeal joint

Microscopic examination of a biopsy from the skin lesion located on the right third metacarpophalangeal joint shows similar pathologic changes to those on the elbow. The granulomatous inflammation extends into the deep reticular dermis (a and b). Fibrin is noted to be present (c and d) and mucin is noted to be absent within the altered dermal collagen surrounded by the granuloma (e and f). (hematoxylin and eosin: x2 = a, x20 = b; periodic acid-Schiff: x4 = c, x40 = d; colloidal iron: x10 = e, x40 = f)