Adult with papular eruption on the central aspect of the face

An otherwise healthy 38-year-old man presented with a 5-week history of multiple slightly erythematous to brown papules that began on the right upper eyelid and progressed over 5 weeks to encompass both periocular and perioral distribution. Despite 1 month of treatment with oral erythromycin and topical metronidazole, his condition progressed (Fig 5). Microscopic examination of a representative lesion on the left infraorbital rim revealed palisaded granulomata with prominent central caseation (Fig 6). Gomori methenamine silver and acid-fast bacilli stains were negative for microorganisms.