Morbihan disease

Author: Dr Olivia Charlton, Resident Medical Officer, St George Hospital, Sydney, NSW, Australia. DermNet NZ Editor in Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy editor: Gus Mitchell. October 2017.


What is Morbihan disease?

Morbihan disease was first described in 1957 by French dermatologist Robert Degos, and is characterised by a firm oedema on the upper portion of the face. Although generally considered as a refractory and chronic form of rosacea, Morbihan disease may exist in the absence of other features of rosacea, and thus may represent a separate disease process.

Morbihan disease

Who gets Morbihan disease?

Morbihan disease usually affects Caucasians in the third and fourth decade of life.

There are only two reports of the disease in skin of colour [1]. It is more common in women than men.

What causes Morbihan disease?

The lymphoedema of Morbihan disease follows the loss of lymph vessel wall integrity and transudation of fluid. [3,4] The cause is unknown, but possible causes have been speculated, such as:

  • Local dysregulation of lymphatic vessels
  • Lymphatic obstruction by granulomas and histiocytes (a type of immune cell) [2]
  • Chronic inflammation due to acne, rosacea or contact dermatitis that destroys supporting connective tissue around dermal lymphatics [3,4].

What are the clinical features of Morbihan disease? 

Morbihan disease is characterised by erythema and solid, non-pitting oedema.

  • Onset is slow — intermittent swelling eventually it becomes permanent infiltration of the skin.
  • It affects the periorbital region, forehead, glabella, cheeks and nose.
  • It is not painful or itchy, but may be aggravated by sun exposure.
  • Other features of rosacea may be present, like telangiectasia, flushing, papules and pustules [5,6].

What are the complications of Morbihan disease?

Persistent facial oedema leads to:

  • Distortion of facial contours.
  • Vision impairment due to narrowed visual field
  • Psychosocial stress
  • Cosmetic concerns.

How is Morbihan disease diagnosed?

There are no biochemical or histopathologic findings specific to Morbihan disease.

Biopsy should be conducted to rule out other diagnoses. Nonspecific histopathology findings include:

  • Perivascular dermal oedema
  • Lymphohistiocytic periadnexal infiltrate
  • Numerous mast cells confirmed by Giemsa stain
  • Mucin confirmed by colloidal iron stain
  • Dilation of lymphatic vessels
  • Non-caseating granulomas
  • Sebaceous gland hyperplasia [7].

Patch testing may also be arranged to exclude allergic contact dermatitis.

What is the differential diagnosis for Morbihan disease?

Differential diagnosis includes other granulomatous and inflammatory facial conditions [8,9].

  • Sarcoidosis — epithelioid granulomas on histology and a positive serum ACE. May be localised to the skin or systemic.
  • Orofacial granulomatosis — painless lip swelling, granulomas on histology, mouth ulcers, mucosal tags, lingua plicata.
  • Systemic lupus erythematosuscutaneous findings include malar rash (butterfly rash), maculopapular rash, mucosal ulcers and photosensitivity. May result in systemic disease affecting the joints, lungs, heart, kidneys, brain, blood and nervous system.
  • Foreign body granuloma — red-brown papules, nodules and plaques in response to tattoo, bovine collagen injection, silicone or paraffin injection, retained sutures, etc. 
  • Scleredema of Buschkesymmetrical hardening of the skin of the neck and upper back typically associated with diabetes mellitus. Caseating epithelioid granulomas on histopathology containing acid-fast bacilli.
  • Lupus vulgaris — red-brown “apple jelly nodules” due to cutaneous tuberculosis (TB).  
  • Cutaneous pseudolymphoma — various conditions that simulate cutaneous lymphoma.

What is the treatment for Morbihan disease?

Morbihan disease is frequently refractory to treatment.

Medical treatments

The antibiotics metronidazole and tetracyclines, minocycline and doxycycline are effective for inflammatory rosacea. Other options are:

  • Isotretinoin 10–20 mg daily for 3–6 months
  • Ketotifen 1 mg daily [7].

Thalidomide, clofazimine and systemic corticosteroids such as prednisone are typically ineffective.

Destructive therapies 

Surgical excision of redundant edematous tissue may be required for a full recovery. Other options are:

Other therapies

Facial massage can be used to improve lymphatic drainage. Contact irritants or allergens should be avoided to aid recovery.

 

Related Information

References

  1. Marks R. Rosacea flushing and perioral dermatitis. In: Rook A, Ebling FJG, Wilkinson DS, Champion RH. Rook’s Textbook of Dermatology. 5th ed. London:Blackwell Scientific Publications; 1992.
  2. Wohlrab J, et al. Persistent erythema and edema of the mid third and upper aspect of the face (morbus morbihan): evidence of hidden immunologic contact urticaria and impaired lymphatic drainage. J Am Acad Dermatol 2005; 52: 592. PubMed
  3. Nagasaka T, et al. Persistent lymphedema in Morbihan disease: formation of perilymphatic epithelioid granulomas as a possible pathogenesis. Clin Exp Dermatol 2008; 33: 764. PubMed
  4. Wohlrab J, et al. Persistent erythema and edema of the mid third and upper aspect of the face (morbus morbihan): evidence of hidden immunologic contact urticaria and impaired lymphatic drainage. J Am Acad Dermatol 2005; 52: 592. PubMed
  5. Reinholz M, Tietze JK, Kilian K, Schaller M, Schöfer H, Lehmann P, Zierhut M, et al. Rosacea - S1 guideline. J Dtsch Dermatol Ges. 2013; 11: 768–80; 768–79. PubMed
  6. Hu SW, Robinson M, Meehan SA, Cohen DE. Morbihan disease. Dermatol Online, J. 2012; 18: 27. PubMed
  7. Jungfer B, Jansen T, Przybilla B, Plewig G. Solid persistent facial edema of acne: Successful treatment with isotretinoin and ketotifen. Dermatology. 1993; 187: 34–7. PubMed
  8. Batra M, et al. Granulomatous rosacea: unusual presentation as solitary plaque. Dermatol Online J 2011; 17: 9. PubMed
  9. Romiti N. Morbus Morbihan: edema e eritema sólido e persistente da face. An Bras, Dermatol. 2000; 75: 599–603. Journal

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