Assessment of Treatment of Refractory Granuloma Faciale With Intralesional Rituximab

Abstract

Importance: Granuloma faciale (GF) is a rare, benign inflammatory dermatosis of unknown cause. Some reports have suggested that it could be part of the spectrum of IgG4-related sclerosing diseases. Granuloma faciale is characterized by single or multiple red-brown nodules, most frequently occurring on the face, and it can produce severe disfigurement. Treatment is difficult, and poor outcomes are often seen. Rituximab is a monoclonal antibody against CD-20 approved by the US Food and Drug Administration for treatment of some autoimmune and tumoral diseases.

Objective: To evaluate the treatment of refractory GF with intralesional rituximab.

Design, setting, and participants: In this case series, 3 patients with biopsy-proved refractory GF who underwent treatment at a dermatology outpatient clinic of a tertiary referral hospital were evaluated. The study was conducted from August 2015 to December 2017.

Interventions: Doses of 0.5 to 1 mL/cm2 of intralesional rituximab, 10 mg/mL, were administered monthly for 6 months and thereafter depending on clinical response. In 2 patients, peripheral blood B-cell counts were monitored before and during treatment, and in 1 patient, only during treatment.

Main outcomes and measures: Reduction in size of the lesions, ultrasonography evaluation, subjective improvement, and adverse events were monitored throughout the course of therapy.

Results: All 3 of the patients were men (ages from 30s to 60s). They showed a significant reduction in the size and thickness of GF both clinically and on ultrasonography evaluation. Two patients had a complete response and the third, a partial response. A reduction in peripheral blood B-cell count was observed in the 3 patients, suggesting that the action of rituximab could be systemic. No severe adverse reactions were reported.

Conclusions and relevance: Intralesional rituximab may represent a novel and well-tolerated therapy for refractory GF.

Figure 1.. Case 2: Granuloma Faciale on the Right Ear and Response to Intralesional Rituximab

A, Red-brown nodule in the lobule of the right ear. B, Marked decrease in size and thickness after 10 administrations of intralesional rituximab.

Figure 2.. Case 3: Granuloma Faciale on the Scalp and Response to Intralesional Rituximab

A, Violaceous plaque on the scalp measuring 14 cm and infiltrated to palpation. B, Marked decrease in size and thickness after 10 administrations of intralesional rituximab.