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Granuloma inframammary adultorum represents a variant of erosive papulonodular dermatosis (EPND) with predominant clinical components of papules and nodules. We describe herein a patient who presented with worsening skin lesions.
Report of a Case
A woman in her 60s with a history of inverse psoriasis presented with 2 months of “draining sores” under her breasts. Prior to the development of the sores, she had experienced a progressive burning sensation and tenderness in the affected areas and had been self-treating the inframammary skin with betamethasone valerate, 0.1%, ointment. Physical examination revealed foul-smelling, well-demarcated, erythematous, macerated plaques with multiple eroded reddish-purple papules and nodules beneath her pendulous breasts extending onto her upper abdomen with areas resembling granulation tissue (Figure, A).
A, Erythematous, macerated papules, nodules, and plaques are evident beneath the breasts extending onto the upper abdomen. B, The affected skin has returned to normal after resolution of the papules, nodules, and plaques.
Potassium hydroxide preparation test results were negative for fungi. Fungal and bacterial cultures were also negative, as were herpes simplex virus and varicella zoster virus polymerase chain reaction findings. Analysis of biopsy specimens showed epidermal hyperplasia with numerous intraepidermal neutrophils and a dermal infiltrate consisting of neutrophils, plasma cells, and eosinophils. Histopathologic findings were compatible with EPND.
The patient was instructed to stop using the betamethasone and to use instead calcipotriene, 0.005%, ointment daily with acetic acid, 0.25%, compresses on the affected areas. Three weeks after her initial visit, the lesions showed significant improvement in redness, nodularity, and odor. At 1-year follow-up, the lesions had not recurred (Figure, B).
Granuloma inframammary adultorum represents a multifactorial irritant dermatitis. When skin is covered with cream or ointment and occluded by clothing, dermatitis can result, especially in cases of prolonged contact. In our patient, the risk factors leading to her condition were the application of corticosteroids, occlusive effects, friction from her brassiere rubbing the skin, and obesity. Long-term contact with clothing wet from perspiration caused by heat retention during hot weather months, infrequent cleaning of affected areas, and history of psoriasis could also have contributed to the development of lesions.
Granuloma gluteal adultorum is a multifactorial irritant dermatitis caused by prolonged contact of urine or feces and infrequent diaper changing. Lesions present as granulomatous-appearing nodules in areas of occlusion.1 Occlusion from topical steroids and anesthetics like benzocaine, powder, paper napkins, plastic pants, detergents, and infections like candidiasis are also aggravating factors.1-4 Our patient demonstrated characteristic lesions of EPND in an unusual location in the setting of these well-known exacerbating factors.
The predominant clinical components of the lesions of our patient were painful papules, nodules, and erosions resembling granulomas clinically. These lesions were probably caused by sweat retention, which caused swelling of keratin in the sweat ducts and inflammation. The histologic findings were compatible with those of irritant dermatitis, similar to those reported in descriptions of EPND.1,2 Also note that granulomas exhibit atypical microscopic characteristics in this condition.1,2
Topical corticosteroids are used to treat a variety of acute and chronic dermatoses, including psoriasis. Our patient applied betamethasone valerate to an intertriginous area, resulting in an unusual clinical presentation of an inframammary eruption similar to granuloma gluteal adultorum, or EPND. Once the corticosteroid application was discontinued, the lesions began to resolve, leading to marked improvement after a few weeks. Our treatment with topical calcipotriene and acetic acid, 0.25%, soaks resulted in resolution of the lesions. The effectiveness of calcipotriene may have resulted from inhibition of epidermal proliferation and stimulation of differentiation of epidermal cells. Acetic acid likely helped restore the acidic pH of the stratum corneum, helping restore normal barrier function.
Based on our patient’s history, physical examination, pathologic findings, and clinical course, she most likely had an inframammary variant of EPND.
Corresponding Author: Clayton B. Green, MD, PhD, Department of Dermatology, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449 (firstname.lastname@example.org).
Published Online: July 9, 2014. doi:10.1001/jamadermatol.2014.352.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Marie Fleisner, Marshfield Clinic Research Foundation Office of Scientific Writing and Publication, for editorial assistance in preparing this article.
Chacón GR, Green CB, Kim SL, Stratman EJ. Granuloma Inframammary Adultorum. JAMA Dermatol. 2014;150(10):1113–1115. doi:10.1001/jamadermatol.2014.352
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