actinic granuloma is an uncommon granulomatous reaction hypothesized to be an autoimmune response to actinic damage to elastic tissue ( o'brien , 1978 ) .
it is more commonly seen in women , with a female  male ratio ranging from 1.2:1 to 2:1 ( gutierrez - gonzalez et al . , 2013 , limas , 2004 , o'brien , 1975 , ragaz and ackerman , 1979 ) .
case studies and observational studies suggest that factors associated with this condition include diabetes mellitus and exposure to sun , radiation , intense light , tanning beds , and high heat ( table  1 ) .
actinic granuloma classically presents as an annular plaque , most commonly on sun - exposed areas of the head , neck , and upper extremities , with an atrophic or hypopigmented center and elevated erythematous borders .
there is also an ocular variant of actinic granuloma , which has been reported to occur as a yellow to pink plaque on the conjunctiva ( konar et al . , 2014 , mittal et al . , 2013 ) .
we present this case and review of the literature to emphasize the association between actinic granuloma and temporal arteritis , a serious inflammatory condition that could lead to blindness if misdiagnosed .
a 62-year - old caucasian male presented during the summer with a 3-month history of asymptomatic papules on the arms , legs , and trunk .
the patient was previously treated with a course of methylprednisolone , which resulted in some improvement .
physical examination revealed multiple tan - to - pink infiltrated annular papules on the chest , back , upper arms , and legs .
laboratory studies showed a normal complete blood count , normal lyme and anaplasma titers , and negative hepatitis b and c serologies .
liver function testing showed aspartate aminotransferase ( ast ) of 57 and alanine aminotransferase ( alt ) of 79 .
erythrocyte sedimentation rate ( esr ) was elevated to 104 mm / hr . histopathologic examination showed an interstitial granulomatous infiltrate in the superficial and mid - dermis composed of histiocytes , lymphocytes , occasional eosinophils , and numerous multinucleated giant cells ( fig .  2 ) .
verhoeff - van gieson stain showed fragmented elastin fibers within the cytoplasm of occasional multinucleated giant cells ( fig . 
periodic acid - schiff stain ( pas ) , acid - fast bacillus ( afb ) , and fite stains were negative .
differential diagnosis based on histopathology included actinic granuloma , interstitial granulomatous dermatitis , interstitial granulomatous drug reaction , and granuloma annulare . given the presence of numerous multinucleated giant cells , findings on the verhoeff - van gieson stain , and solar elastosis with the time of presentation during summer , the patient was diagnosed with actinic granuloma .
although the patient s headaches were not classic enough to prompt an earlier workup for temporal arteritis , temporal artery biopsy was performed because the patient complained of headaches and had an elevated esr .
biopsy results revealed giant cell arteritis of the right temporal artery , and verhoeff - van gieson stain revealed focal disruption in the temporal artery internal elastic lamina .
the patient was started on hydroxychloroquine 200 mg orally bid and prednisone 2.5 mg daily for his temporal arteritis , with partial clearance of his skin lesions .
though his skin lesions drastically improved on this regimen , persistent esr elevation required an increase in prednisone to 40 mg po daily and the addition of methotrexate .
the term actinic granuloma was first proposed by john obrien in 1975 after he observed histologic similarities in patients with annular lesions .
because of its clinically similar appearance to granuloma annulare , some critics have questioned whether the condition should be classified as a separate entity or simply as granuloma annulare occurring in sun - damaged skin ( ragaz and ackerman , 1979 ) .
others have accepted the distinction but have reclassified the lesions morphologically as annular elastolytic giant cell granuloma ( hanke et al . , 1979 ) .
both of these terms , however , are descriptive only , while actinic granuloma offers an etiologic implication ( limas , 2004 ) . histopathologic examination of actinic granuloma shows an inflammatory process limited to the superficial dermis , with usually nonpalisading granulomas , greater frequency of multinucleated giant cells , solar elastosis , and no increase in mucin ( al - hoqail et al . , 2002 ) .
this is in contrast to the deep , as well as superficial , dermal infiltrate with more commonly palisading granulomas ; reduced frequency of multinucleated giant cells ; and increased mucin deposition seen in granuloma annulare ( al - hoqail et al . , 2002 ) .
four general histologic patterns of actinic granuloma have been described : histiocytic , giant cell , necrobiotic or vascular , and sarcoid ( o'brien , 1985 ) .
the giant cell pattern is the original pattern , initially consisting of a small granuloma that becomes annular as it advances into elastotic tissue nearby .
the necrobiotic variant , also known as the vascular variant , consists of areas of ischemic necrosis in the advancing granulomatous edge .
lastly , the sarcoid variant often demonstrates atrophic stroma , fibrosis , and a persistent inflammatory reaction . of the four histologic patterns ,
the giant cell and necrobiotic histologic patterns appear to be more common patterns in females than males ( gutierrez - gonzalez et al . , 2013 ) .
in general , treatment for actinic granuloma includes topical and intralesional corticosteroids , psoralen ultraviolet a therapy , antimalarials , cyclosporine , methotrexate , and cryotherapy ( reisenauer et al . , 2012 ) .
case reports and observational studies have demonstrated variable results with these treatment modalities ( table  1 ) .
temporal arteritis , also known as giant cell arteritis ( gca ) , is a form of medium - to - large - vessel vasculitis with the possible complication of vision loss if left untreated ( smith and swanson , 2014 ) .
criteria for diagnosis include the presence of three or more of the following : age of 50 years or older , new headache , a clinically abnormal temporal artery , an esr greater than 50 mm / hr , and an abnormal temporal artery biopsy ( smith and swanson , 2014 ) .
interestingly , temporal arteritis occurs preferentially in women ( smith and swanson , 2014 ) .
giant cell arteritis has been most notably associated with polymyalgia rheumatica ( smith and swanson , 2014 ) .
comorbidities in addition to polymyalgia rheumatic in gca include osteoporosis , cardiovascular conditions , diabetes mellitus , hypokalemia , and pseudophakia , all conditions that appear to have a high burden in the populations affected by gca ( petri et al . , 2015 ) .
temporal arteritis has also been associated with extreme ear pain ( aui - aree et al . , 2010 ) .
other cutaneous conditions and manifestations with which temporal arteritis has had rare associations include psoriatic arthritis , scalp abscess , scalp ulceration with necrosis , butterfly rash of the face , tongue changes , gangrene or ulcers of the leg , purpura and ecchymoses , urticaria , edema , lividity , tender nodules , hyperpigmentation , tortuous arteries , and supravascular pallor ( aui - aree et al . , 2010 , baum et al . , 1982 , corli et al .
the association between actinic granuloma and temporal arteritis was first postulated in 1978 by john obrien ( see also lau et al . , 1997 ) .
a few years later , the same author noted a histologic finding of actinic arteritis in a small vessel within the dermis of a polymyalgia patient ( lau et al .
the underlying basis of this association is thought to be related to actinic degeneration of elastic tissue not only of the skin , but also of the internal elastic lamina of vessels ( gutierrez - gonzalez et al . , 2013 , o'brien and regan , 1999 ) .
since then , few reports in the literature have demonstrated the association between actinic granuloma and temporal arteritis ( lau et al . , 1997 , shoimer and wismer , 2011 ) ;
interestingly , all cases demonstrating the association have occurred in males , despite the higher prevalence of actinic granuloma in females .
our patient had a unique clinical presentation that differed from previously reported cases of actinic granuloma associated with temporal arteritis .
( 1997 ) described two elderly gentlemen who presented with solitary lesions on the forehead , and shoimer and wismer ( 2011 ) described an elderly gentleman who presented with erythematous annular confluent plaques in predominantly sun - exposed locations .
our case further supports the possibility of temporal arteritis in a variety of presentations of actinic granuloma .
given the severe consequences of temporal arteritis , most notably blindness , we emphasize the importance of ruling out temporal arteritis in any patient presenting with actinic granuloma and headaches .
if an associated temporal arteritis is suspected , systemic corticosteroids should be started to suppress the immune system and prevent blindness .
 actinic granuloma is a rare granulomatous reaction that is more commonly seen in females and thought to occur as an autoimmune response to actinic damage of elastic tissue . 
 we discuss a case of a patient with actinic granuloma presenting with concomitant temporal arteritis . 
 our case and review of the literature emphasize the association between actinic granuloma and temporal arteritis , a serious inflammatory condition that could lead to blindness if misdiagnosed . 