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A 75-year-old, obese woman is referred for evaluation of a rash affecting her abdomen and upper arms. The condition was first noted 6 months prior to evaluation and is asymptomatic. Medical history includes adult-onset diabetes and hypertension. Prior treatments for the rash include ketoconazole shampoo and triamcinolone cream, both of which were ineffective.
Can you diagnose this condition?
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Granuloma annulare is a self-limited, asymptomatic, granulomatous, inflammatory disease. Morphologic forms include subcutaneous, perforating, localized, and disseminated, with disseminated or generalized granuloma annulare representing 2.8% to 15% of all cases.1 Although the etiology is unknown, associations with diabetes, thyroid disease, malignant disease, disorders of lipid metabolism, and infections including HIV have been described.1
Typical presentation of granuloma annulare involves multiple wide-spread, erythematous-to-hyperpigmented papules that may coalesce to form annular plaques. A papular morphology in the absence of annular plaques is a less-common presentation.2 Diagnosis is made clinically and can be confirmed by skin biopsy.
Granuloma annulare involves the dermis with histopathologic features that include necrobiosis and degenerating collagen surrounded by lymphohistiocytes and granuloma formation.3,4 Often resistant to therapeutic modalities, disseminated granuloma annulare may persist for decades, remit, and recur spontaneously.3 Treatment is not standardized; a variety of therapeutic regimens — such as topical and systemic steroids, isotretinoin, dapsone, cryosurgery, phototherapy, pentoxifylline, hydroxychloroquine, cyclosporine, topical imiquimod, calcineurin inhibitors, chlorambucil, antimalarials, nicotinamide, and tumor necrosis factor inhibitors — may induce remission.1,3
Lauren Ax, MSPAS, PA-C, is a physician assistant at the DermDox Dermatology Center in Hazleton, Pennsylvania, and Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.
References
- Pătraşcu V, Giurcă C, Ciurea RN, Georgescu CV. Disseminated granuloma annulare: study on eight cases. Rom J Morphol Embryol. 2013;54(2):327-331.
- Bansal M, Pandey SS, Manchanda K. Generalized papular granuloma annulare. Indian Dermatol Online J. 2012;3(1):74-76.
- Lukács J, Schliemann S, Elsner P. Treatment of generalized granuloma annulare – a systematic review. J Eur Acad Dermatol Venereol. 2015;29(8):1467-1480.
- Ran M, Wang Y. Generalized granuloma annulare associated with diabetes mellitus. N Engl J Med. 2016;375(10):e21.
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