Granuloma gluteale infantum (GGI), previously known as vegetating potassium bromide toxic dermatitis or vegetating bromidism, is a rare skin disorder of controversial etiology characterized by oval, reddish purple granulomatous nodules on the gluteal surfaces and the groin areas of infants. Lesions can also be found in intertriginous areas (eg, neck, 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.
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Photograph of a case of 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, from Germany, first reported 6 cases of granuloma gluteale infantum.[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. 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 granuloma gluteale infantum, 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]
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Photograph of a case of granuloma gluteale adultorum.
Advances in absorbent diaper technology using synthetic materials have significantly reduced diaper-associated inflammatory skin conditions in recent decades. Also see Pediatrics, Diaper Rash and Diaper Dermatitis.
Granuloma gluteale infantum is the result of chronic maceration. Diapering-related items (eg, diapers, plastic pants, paper napkins, laundry detergents, starch, powder), halogenated corticosteroids, candidal infection, and urine and feces are possible contributing factors.[6, 7, 8]
Sparing of deep body folds suggests that contact occlusion is predisposing.
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.
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 of the diaper area leads to altered dermal collagen, which, in turn, stimulates an inflammatory response.
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 related to adult urinary incontinence.[4, 5, 9]
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.
Instruct the caregivers of patients to minimize potential contact irritants, which may include cloth or synthetic diapers, paper napkins, plastic pants, and halogenated corticosteroids.
Emphasize to the caregivers of patients the importance of maintaining an intact skin barrier, gently cleansing the diaper area, and protecting the skin from additional trauma.
Most infants with granuloma gluteale infantum 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]
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.
Granuloma gluteale infantum exhibits the following histologic characteristics[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
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Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic fea....
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Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic fea....
Treatment is generally not required because lesions spontaneously resolve.[16] Treatment of any initiating inflammatory process, with its associated maceration and secondary infection, is beneficial.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Some of the treatments used include barrier products, intralesional corticosteroids, and flurandrenolide-impregnated tape.[17]
These agents are the treatment of choice. Protective or preventive measures include barrier products to seal the skin from exogenous factors, such as urine, feces, and other external irritants, which may predispose an individual to granuloma gluteale.
Clinical Context:
Triamcinolone is for inflammatory dermatosis responsive to steroids; it decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Intramuscular injections may be used for widespread skin disorders or intralesional injections may be used for localized skin disorders.
Each mL of sterile, aqueous suspension contains triamcinolone acetonide 10 mg. Nonmedicinal ingredients include benzyl alcohol, carboxymethylcellulose sodium, hydrochloric acid, polysorbate, sodium chloride, sodium hydroxide, and water. It is suspended in sterile sodium chloride solution at a final concentration of 2.5-5 mg/mL.
Clinical Context:
Flurandrenolide is a topical anti-inflammatory agent supplied as a 4 mcg/cm2 topical adhesive tape. Despite the possible causative role of topical corticosteroids in some cases of granuloma gluteale infantum, various hypertrophic lesions have been effectively thinned in 3 days with the use of this treatment.
Intralesional administration is indicated to treat localized hypertrophic, infiltrated inflammatory lesions. Granuloma gluteale infantum, granuloma gluteale adultorum, and diaper area granuloma of the aged fit into this category of lesions. Flurandrenolide-impregnated tape, which combines a barrier with an anti-inflammatory action, has been reported to be beneficial.
What is granuloma gluteale infantum (GGI)?What is the pathophysiology of granuloma gluteale infantum (GGI)?What causes granuloma gluteale infantum (GGI)?What is the prevalence of granuloma gluteale infantum (GGI)?What are the sexual predilections of granuloma gluteale infantum (GGI)?Which age groups have the highest prevalence of granuloma gluteale infantum (GGI)?What is the prognosis of granuloma gluteale infantum (GGI)?What is included in the patient education about granuloma gluteale infantum (GGI)?Which clinical history findings are characteristic of granuloma gluteale infantum (GGI)?Which physical findings are characteristic of granuloma gluteale infantum (GGI)?What are the possible complications of granuloma gluteale infantum (GGI)?What are the differential diagnoses for Granuloma Gluteale Infantum?Which lab tests are performed in the workup of granuloma gluteale infantum (GGI)?What is the role of biopsy in the workup of granuloma gluteale infantum (GGI)?Which histologic findings are characteristic of granuloma gluteale infantum (GGI)?How is granuloma gluteale infantum (GGI) treated?How is granuloma gluteale infantum (GGI) prevented?What is included in the long-term monitoring of granuloma gluteale infantum (GGI)?What is the role of medications in the treatment of granuloma gluteale infantum (GGI)?Which medications in the drug class Corticosteroids are used in the treatment of Granuloma Gluteale Infantum?Which medications in the drug class Protectants are used in the treatment of Granuloma Gluteale Infantum?
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
Photograph of a case of granuloma gluteale infantum.
Photograph of a case of granuloma gluteale adultorum.
Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X100).
Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X450).
Photograph of a case of granuloma gluteale infantum.
Photograph of a case of granuloma gluteale adultorum.
Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X100).
Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X450).