a 52-year - old thai woman presented with asymptomatic annular erythematous plaques on the forehead and both cheeks that persisted for 2 years .
dermatologic examination showed few discrete annular erythematous plaques on her forehead and both cheeks , 15 cm in diameter .
there were solar lentigines and telangiectasias on the malar area , nose , and forehead as shown in fig . 1 and fig
the routine histopathology demonstrated nodular and interstitial inflammatory cell infiltrate of histiocytes intermingled with some lymphocytes in the dermis as shown in fig .
elastic stain showed elastotic material phagoticized by multinucleated cells and marked decrease of elastic tissue in some foci of the affected dermis ( fig .
4 ) . according to the clinical and histopathological findings , the dermatologic diagnosis was actinic granuloma ( ag ) .
complete blood count , liver enzyme , fasting blood glucose , and glycated hemoglobin were within normal range .
the patient 's dermatologic condition was treated with prednisolone 15 mg / day for 6 weeks with a good response
currently , she has been treated with hydroxychloroquine ( 200 mg / day ) , topical 0.1% mometasone furoate cream , broad spectrum sunscreen , and sun avoidance with partial improvement .
it was also termed annular elastolytic giant cell granuloma , atypical necrobiosis lipoidica of the face and scalp , miescher 's granuloma of the face , and granuloma multiforme [ 1 , 2 , 3 , 4 ] .
ultraviolet ( uv ) radiation , especially uva , and heat are recognized as causal factors , by changing the antigenicity of elastic fibers . the immune response mediated by helper t cells to degenerated elastic tissue
the typical cutaneous lesion of ag is an initially smooth , elevated , nonscaly , erythematous papule which centrifugally extends to an annular plaque with central clearing .
they are usually distributed on chronically sun - exposed areas such as the face , neck , upper back , forearms , and dorsum of the hands .
apart from the skin , conjunctival involvement has been reported in a few cases [ 6 , 7 ] .
there are some reports on the association between ag and internal diseases such as hematologic and solid malignancy , monoclonal gammopathy , temporal arteritis , erythema nodosum , and x - linked dominant protoporphyria [ 8 , 9 , 10 , 11 ] .
diabetes mellitus has been found in about 3740% of patient with ag , and may be caused by injury of elastic fiber from hyperglycemic state . as for the renal condition , focal
segmental glomerulosclerosis has been described in association with various granulomatous diseases ( e.g. , sarcoidosis , wegener 's granulomatosis , churg - strauss syndrome , and kimura 's disease ) [ 13 , 14 , 15 , 16 ] .
these include granuloma annulare , erythema annulare centrifugum , annular lichen planus , secondary syphilis , necrobiosis lipoidica , tinea corporis , and tuberculoid leprosy .
the best method to obtain a precise histopathology is an elliptical biopsy across the annular rim and stained with elastic van gieson to demonstrate the three zones of elastic tissue change . in the first zone
, solar elastosis is identified in the surrounding unaffected skin . in the second zone ,
a granulomatous reaction consisting of histiocytes and foreign - body type multinucleated cells is seen , with engulfment of elastotic fibers , representing the annular rim . in the third zone
, an absence of elastic tissue in the superficial dermis is found in the center of the plaque . due to aesthetic concern in our case
topical corticosteroids , intralesional corticosteroids , systemic corticosteroids , topical calcineurin inhibitors , phototherapy and photochemotherapy ( narrowband uvb , puva , re - puva ) have been used with some benefit [ 18 , 19 , 20 ] .
cyclosporine a , dapsone , pentoxifylline , isotretinoin , and acitretin have been reported to be effective in some cases [ 21 , 22 , 23 ] .
there are a few case reports with positive results from antimalarial therapy ( chloroquine and hydroxychloroquine ) .
to prevent the development of new lesions , patients should be instructed to avoid sun exposure and regularly use sunscreen .
our patient had good response to a short course of low - dose prednisolone . however , rapid relapse occurred after the treatment was discontinued .
currently , she has been treated with hydroxychloroquine ( 200 mg / day ) , topical 0.1% mometasone furoate cream , broad spectrum sunscreen , and sun avoidance with partial improvement . to the best of our knowledge ,
the correlation between ag and focal segmental glomerulosclerosis is still unidentified , further investigation is needed to establish the relationship between these two conditions .
the authors declare no conflicts of interest . there was no funding for this work .
 actinic granuloma is an uncommon granulomatous disease , characterized by annular erythematous plaque with central clearing predominately located on sun - damaged skin . 
 the pathogenesis is not well understood , ultraviolet radiation is recognized as precipitating factor . 
 we report a case of a 52-year - old woman who presented with asymptomatic annular erythematous plaques on the forehead and both cheeks persisting for 2 years . 
 the clinical presentation and histopathologic findings support the diagnosis of actinic granuloma . during that period of time 
 , she also developed focal segmental glomerulosclerosis . 
 the association between actinic granuloma and focal segmental glomerulosclerosis needs to be clarified by further studies . 
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