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A 69-year-old woman requests a second opinion because of a persistent skin condition. Her eruption had been present for months and was resistant to a variety of topical medications, including antifungals. The patient’s medical history was positive for type 2 diabetes and arthritis. Physical examination revealed multiple annular, erythematous patches and plaques scattered on the upper and lower extremities and trunk. The lesions were devoid of scale and exhibited central clearing. The majority had slightly raised borders.
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The patient was diagnosed with granuloma annulare (GA), a benign, self-limited condition of unknown etiology. The condition affects patients of all ages but is more common in those younger than 30 years of age and in women.1
GA occurs in several forms, including localized, generalized, and subcutaneous.2 The localized subtype is most common and usually presents on the dorsal or lateral surfaces of the hands and feet. Classical appearance is an annular flesh-colored to dusky plaque with a raised border. Size may exceed 1.0 cm. Generalized GA usually affects adult women and manifests as multiple erythematous papules, patches, and/or plaques. The trunk and upper thighs are mainly involved, although lesions may occur on the face. Subcutaneous or deep GA occurs primarily in children and is characterized by firm asymptomatic nodules.
The diagnosis of GA is usually made based on clinical appearance. Biopsy will reveal palisading granulomatous inflammation in addition to dermal collagen degeneration surrounded by macrophages, neutrophils, and multinucleated giant cells.1,2
Isolated lesions of GA may be precipitated by trauma, although the underlying pathogenesis is uncertain. A cell-mediated response to an antigen has been postulated3; although an infectious etiology is possible,4 none has been verified.5 Treatment options of localized disease include topical and intralesional steroids and cryosurgery. Disseminated disease may respond to an antibiotic regimen6 or isotretinoin.7
Megha D. Patel is a student at the Commonwealth Medical College, Scranton, Pennsylvania.
Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College and an adjunct assistant professor of dermatology at the University of Pennsylvania Medical College. He practices dermatology in Hazleton, Pennsylvania.
References
- Smith MD, Downie JB, DiCostanzo D. Granuloma annulare. Int J Dermatol. 1997;36(5): 326-333.
- Habif TP. Granuloma annulare. In: Clinical dermatology. 5th ed. Philadelphia: Elsevier; 2010:976-977.
- Keimig EL. Granuloma annulare. Dermatol Clin. 2015;33(3):315-329.
- Ziemer M, Grabner T, Eisendle K, et al. Granuloma annulare—a manifestation of infection with Borrelia? J Cutan Pathol. 2008;35(11):1050-1057.
- Avitan-Hersh E, Sprecher H, Ramon M, Bergman R. Does infection play a role in the pathogenesis of granuloma annulare? J Am Acad Dermatol. 2013;68(2):342-343.
- Marcus DV, Mahmoud BH, Hamzavi IH. Granuloma annulare treated with rifampin, ofloxacin, and minocycline combination therapy. Arch Dermatol. 2009;145(7):787-789.
- Schleicher SM, Milstein HJ, Lim SJ, Stanton CD. Int J Dermatol. 1992;31(5):371-372.
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