Sir,

Chronic, painless facial nodules in children, which may be misdiagnosed as chalazions if located on eyelids are subject of a new entity called ‘idiopathic facial aseptic granuloma’ (IFAG). IFAG is a dermatological disorder characterized by solitary eyelid nodules or accompanying facial nodules located on the cheeks with an unknown etiology.1 The role of trauma and insect bite has been discussed.2 Nodules include a discharge of pus. Cultures are negative, except in cases of superinfection.

Eyelid nodules resemble nodules of meibomian cysts (chalazions) (see Figure 1). Ultrasonography of IFAG nodules shows a well-demarcated hypoechoic lesion located in dermis only.3 But chalazions—which are due to meibomian gland inflammation—are located inside eyelid tarsus.4 IFAG nodules are thought to be related to a granulomatous process surrounding an embryological residue, rather than inflammation of meibomian glands.1 Chalazions are not accompanied by facial nodules unless they are related to rosacea.4 IFAG lesions on eyelids are often self limited and heal without any scar,1 whereas surgical management is necessary in most cases of chalazia, especially for the large ones.

Figure 1
figure 1

Eyelid nodule of IFAG.

Full size image

Characteristic appearance of the eyelid nodules and accompanying facial lesions are typical for IFAG. But coexistence of facial and eyelid nodules is also a common feature for ocular rosacea. These two diseases demonstrate major differences despite this overlapping clinical picture. As a major difference, conjunctival hyperemia, blepharoconjonctivitis, or keratitis-like ocular manifestations are typical for rosacea and very rarely seen with IFAG.1 Oral antibiotic regimens like oral clarithromycin or erythromycin fasten the healing process,5 unlike ocular rosacea, which always necessitates systemic antibiotic treatments–even surgical interventions in unresponsive cases.

Despite these differences, some authors assume it to be early childhood rosacea,1 whereas some others regard it as rosacea’s granulomatous form.6

Ophthalmic and dermatological evaluation in IFAG is important, as these cases are recommended to be followed up for pediatric rosacea development—although the association is not exactly verified. Associated with rosacea or not, we believe that awareness of this new dermatological disorder by the ophthalmologists is the most important point, to avoid unnecessary surgical interventions, because of its good response to oral antibiotics.