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A 62-year-old woman is referred for evaluation of an extensive rash. The condition was first noted on her right upper arm about 4 months ago. This was followed by involvement of her other arm and trunk. The arm rash failed to respond to topical therapy with ketoconazole cream and a 2-week course of oral terbinafine followed by a 4-week course of topical triamcinolone cream. Throughout, the rash has remained asymptomatic. She is currently on metformin for control of type 2 diabetes. Examination reveals multiple annular patches with slightly raised and pronounced dull-red borders.
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Granuloma annulare is a self-limited, granulomatous inflammatory disease that is asymptomatic but often proves of cosmetic concern. The condition was first described in 1895 in an 11-year-old child who presented with a “ringed eruption of the fingers.”1 Most cases are localized; however, other forms include subcutaneous, perforating, and disseminated.2 The latter represents between 2.8% to 15% of all cases.3 Several disorders have been associated with disseminated granuloma annulare including diabetes, thyroid disease, malignancies, and HIV.4,5
Clinically, granuloma annulare presents with multiple widespread erythematous to hyperpigmented macules or papules that may coalesce to form annular plaques. Histopathology reveals necrobiosis and degenerating collagen surrounded by palisading lymphohistiocytes. Multinucleated giant cells are a common finding. Dermoscopy findings are variable and may reveal unfocused vessels on a reddish background along with white or yellow‐orangish areas.6 The pathogenesis of granuloma annulare is not known although recent studies implicate activation of the T helper type 1 (Th1) cell and Janus kinase-signal transducer and activators of transcription (JAK-STAT) pathways.2
Disseminated GA may persist for years or spontaneously remit. Treatment is not standardized and a variety of therapeutic regimens have been reported to induce remission including phototherapy, pentoxifylline, hydroxychloroquine, cyclosporine, chlorambucil, isotretinoin, antimalarials, apremilast, and tumor necrosis factor (TNF)/JAK inhibitors.2
Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
References
1. Colcott-Fox T. Ringed eruptions of the fingers. Br J Dermatol. 1895;7:91-95.
2. Joshi TP, Duvic M. Granuloma annulare: an updated review of epidemiology, pathogenesis, and treatment options. Am J Clin Dermatol. 2022;23(1):37-50. doi:10.1007/s40257-021-00636-1
3. Bansal M, Pandey SS, Manchanda K. Generalized papular granuloma annulare. Indian Dermatol Online J. 2012;3(1):74-76. doi:10.4103/2229-5178.93492
4. Patrascu V, Giurca C, Ciurea R, Gerogescu C. Disseminated granuloma annulare: study on eight cases. Rom J Morphol Embryol. 2013;54(2):327-314
5. Ran, M., & Wang, Y. (2016). Generalized Granuloma Annulare Associated with Diabetes Mellitus. N Engl J Med. 2016;375(10):e21. doi:10.1056/NEJMicm1513798
6. Kalantari Y, Peymanfar AA, Mahmoudi H, Daneshpazhooh M, Etesami I. Dermoscopy of cutaneous granulomatous disorders: a study of 107 cases. Skin Res Technol. 2023;29(1):e13273. doi:10.1111/srt.13273
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