Background
Granuloma gluteale infantum (GGI), previously known as vegetating potassium bromide toxic dermatitis or vegetating bromidism, is a rare skin disorder of controversial etiology that is characterized by oval reddish-purple granulomatous nodules on the gluteal surfaces and the groin areas of infants (see the image below). Lesions can also be found in intertriginous areas (eg, neck and axilla). The long axis of most lesions runs parallel to the skin lines of cleavage or maximum skin tension. The lesions typically are self-limited.
View Image | Granuloma gluteale infantum. |
A similar eruption may have been described in 1891 and in 1962 as vegetating bromidism due to the application of bromide ointment. In 1971, Tappeiner and Pfleger first reported six cases of GGI.[1] In subsequent years, similar episodes were reported in other parts of Europe, Japan, and the United States.
Similar granulomas have been noted in adults confined to bed and women who overuse vaginal preparations such as Vagisil (Combe Inc, White Plains, NY). These conditions are referred to as pseudoverrucous nodules of the vulva, granuloma gluteale adultorum, and diaper area granuloma of the aged.[2, 3] In contrast to GGI, the adult versions are observed only in genitocrural regions and not in intertriginous areas; nodules in the adult versions are often eroded, and they do not show an arrangement parallel to the skin lines.[4, 5]
View Image | Granuloma gluteale adultorum. |
Advances in absorbent diaper technology using synthetic materials have significantly reduced diaper-associated inflammatory skin conditions. For further information, see Diaper Rash and Diaper Dermatitis (Diaper Rash).
Etiology
GGI is the result of chronic maceration. Sparing of deep body folds suggests that contact occlusion is predisposing. Diapering-related items (eg, diapers, plastic pants, paper napkins, laundry detergents, starch, and powder), urine and feces, halogenated corticosteroids, and candidal infection are possible contributing factors.[6, 7, 8, 9]
Urine can increase the pH of the diaper-covered area, promoting the action of fecal proteases and lipases. Together, urine and feces can irritate diapered skin, increasing its permeability and susceptibility to other irritants. Van et al reported a case of erosive diaper dermatitis related to adult urinary incontinence.[4]
Most patients, including infants with facial and neck lesions, have previously been treated with a topical fluorinated steroid. This observation suggests a causative role for topical fluorinated steroids in this skin disorder. Absorption of corticosteroid preparations through inflamed skin in the diaper area leads to altered dermal collagen, which, in turn, stimulates an inflammatory response.
Candida hyphae are detected in skin biopsy specimens obtained from some, but not all, patients. Intradermal testing to Candida albicans antigen does not elicit immediate or delayed hypersensitivity. Serum precipitates to C albicans and Candida parapsilosis are not found.
Epidemiology
GGI is a rare condition; only approximately 30 cases have been reported worldwide. It develops in the diaper area of infants aged 4-9 months. Males have a higher incidence of GGI than females do.
Prognosis
The lesions persist for 3-6 weeks, followed by spontaneous regression over 2-4 weeks. Residual brown hyperpigmented macules and lax, atrophic scars are observed in some patients.
Patient Education
Caregivers of patients with GGI should be instructed to minimize potential contact irritants, which may include cloth or synthetic diapers, paper napkins, plastic pants, and halogenated corticosteroids. They should also be educated regarding the importance of maintaining an intact skin barrier, gently cleansing the diaper area, and protecting the skin from additional trauma.
History
Most infants with granuloma gluteale infantum (GGI) have a history of a preceding inflammatory skin condition in an area of seborrheic or candidal dermatitis or contact with a known irritant.[10, 11] These conditions have been treated with a variety of topical agents, including fluorinated corticosteroids.[12, 13]
Physical Examination
Lesions associated with GGI are characterized by the following (see the image below)[14] :
Presence of one to 30 lesions in the affected area
Reddish-purple to reddish-brown color
Nodules that are 5-40 mm in diameter
Oval, firm-to-hard, discrete dermal nodules with smooth or slightly lichenified surfaces
Alignment with the long axis parallel to the skin folds
Location on the gluteal surfaces, in the groin area, and on the upper thighs, lower abdomen, or, rarely, the neck and face
Absence of involvement of the inguinal folds and the gluteal cleft (presumably because diaper contact is absent)
View Image | Granuloma gluteale infantum. |
Complications
Discomfort, secondary infections, and scars may occur in the area of the lesions. Complications may include secondary bacterial or candidal infections and acquired contact hypersensitivity to topical medications.
Laboratory Studies
The following investigations may be performed to exclude other entities in the differential diagnosis for granuloma gluteale infantum (GGI):
Periodic acid-Schiff staining of biopsy specimens to rule out fungi
Potassium hydroxide slide mounts and fungal culture of biopsy specimens
Fite staining of biopsy specimens for acid-fast bacilli
Warthin-Starry stain of biopsy specimens for spirochetes
Polarizing microscopy of biopsy specimens for foreign bodies or crystals
Rapid plasma reagin test for syphilis
Procedures
Biopsy of lesions is warranted, followed by hematoxylin and eosin staining of tissue sections.
Histologic Findings
GGI exhibits the following histologic characteristics (see the images below)[15] :
Parakeratotic stratum corneum
Hyperkeratosis and acanthosis of the epidermis
Dense, superficial, and deep inflammatory infiltrate composed of lymphocytes, histiocytes, plasma cells, and a variable number of focal aggregates of neutrophils and eosinophils forming microabscesses
Absence of foreign body giant cells
Dilatation, elongation, and proliferation of dermal blood vessels
Extravasation of red blood cells and deposits of hemosiderin
No fibrous proliferation, mitosis, or spindle cell formation
Presence of starch granules in the lesions
Intracytoplasmic structures resembling rickettsialike bodies within dermal macrophages
View Image | Photomicrograph shows histologic features of granuloma gluteale adultorum. Granuloma gluteale infantum has identical histologic features (original mag.... |
View Image | Photomicrograph shows histologic features of granuloma gluteale adultorum. Granuloma gluteale infantum has identical histologic features (original mag.... |
Medical Care
Treatment of granuloma gluteale infantum (GGI) is generally not required, because lesions typically resolve spontaneously.[16] When treatment is administered, options include barrier products (used to seal the skin from exogenous factors that may predispose to GGI, such as urine, feces, and other external irritants), intralesional corticosteroids (used to treat localized hypertrophic, infiltrated inflammatory lesions such as GGI), and flurandrenolide-impregnated tape (which combines barrier function with anti-inflammatory activity).[17]
Ramos Pinheiro et al reported successful use of the calcineurin inhibitor pimecrolimus in a 0.1% cream to treat GGI.[8] A subsequent report by Leung et al reported successful treatment of recalcitrant GGI with the calcineurin inhibitor tacrolimus in a 0.03% ointment.[18]
Treatment of any initiating inflammatory process, with its associated maceration and secondary infection, is beneficial.
Prevention
Caregivers of patients with GGI should discontinue the use of diapers on them to the extent possible. Contact irritants should be avoided. The use of protective barrier products should be instituted.
Long-Term Monitoring
Care must be taken to keep the diaper area clean and to exercise precautions against further irritation.
Author
Marlene T Dytoc, MD, PhD, FRCPC, Clinical Professor of Medicine, Division of Dermatology and Cutaneous Sciences, University of Alberta Faculty of Medicine and Dentistry, Canada
Disclosure: Nothing to disclose.
Specialty Editors
Michael J Wells, MD, FAAD, Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology
Disclosure: Nothing to disclose.
Van Perry, MD, Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio
Disclosure: Nothing to disclose.
Chief Editor
Dirk M Elston, MD, Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine
Disclosure: Nothing to disclose.
Additional Contributors
Alfons Krol, MD, FRCPC, Associate Professor, Department of Medicine, Division of Dermatology and Cutaneous Sciences, University of Alberta at Edmonton
Disclosure: Nothing to disclose.
Melody Cheung-Lee, MD, Staff Physician, Department of Dermatology, University of Alberta
Disclosure: Nothing to disclose.
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