Perforating Granuloma Annulare with Cysts and Comedones

A 71-year-old Caucasian woman presented with lesions on both elbows. A physical examination revealed arcuate plaques with raised erythematous edges and central clearing. Comedones and cysts were evident on the border of the lesions. The dermatoscopic view showed the presence of pores, in addition to granuloma annulare changes. The biopsies showed changes according to granuloma annulare, but the granulomas were closely related to comedones and cysts. Furthermore, the presence of elastophagocytosis via multinucleated Langhans-type giant cells was evident. Verhoeff-van Gieson staining highlighted the transepithelial elimination of elastic fibers in the bottom of some cysts. The presence of comedones or cysts is exceptional in granuloma annulare. Only four similar cases have been reported. Although all previous cases showed lesions in sun-exposed areas over photodamaged skin, only our case showed transepithelial elimination of elastic fibers. Diabetes mellitus (DM) could play a role in the pathogenesis of this variant of actinic granuloma annulare, because most cases are associated with uncontrolled DM and the lesions improve after DM is controlled.