GRANULOMA ANNULARE

By Gary M. White, MD

Granuloma annulare A red, dermal, annular, non-scaly plaque is typical.


Granuloma annulare (GA) represents a benign, inflammatory, delayed hypersensitivity reaction in the skin to an as of yet unidentified antigen.

Clinical

The common and localized form of GA usually presents as red, dermal papule forms and spreads outward involuting centrally. Later, multiple dermal papules linked together form spreading, annular rings. Localized GA is most common on the dorsa of the hands but lesions occur elsewhere, e.g. the elbows, fingers, palms, dorsa of the feet, etc.

Nodular GA

Nodular or subcutaneous GA presents as painless, firm subcutaneous nodules and occurs almost exclusively in children, usually on the legs.

Papular, Umbilicated and Perforating GA

Papular, umbilicated GA presents as umbilicated papules with a keratotic core. In the past, perforation was thought to occur, but this is rarely true.

Disseminated Form

A disseminated or generalized form may occur. It represents about 10% of overall cases of GA and is much more common in adults. Its response to therapy is poor and usually does not spontaneously remit. Adalimumab may be helpful here (see below). The morphology may be annular or papular.

Other forms

A rare palmoplantar form occurs (see image below) and may present acutely. Annular Elastolytic Giant Cell Granuloma is considered by some a variant of GA as is Actinic Granuloma (photodistributed GA).

Differential Diagnosis

Although annular, there is no scale as seen in tinea. Any dermal infiltrative process might be considered (e.g. sarcoidosis).

Treatment

If few in number, triamcinolone 5 mg/cc may be injected into the border. Usually one injection is sufficient for any single lesion. If many lesions are present, and IL steroid is impractical or not desired, a potent topical steroid may be tried.

Any sort of trauma may improve GA. All of the following have been reported to improve GA: intralesional saline, biopsy, incision of lesions, scarification (i.e., the use of a 19-gauge needle drawn across the lesion until capillary bleeding occurs), repetitive pricking and cryotherapy.

Tumor necrosis factor (TNF)-α inhibitors have been reported to improve GA. Adalimumab seems to be the most promising with anecdotal reports of rapid clinical response, generally within 2 to 6 weeks, with sustained remission after therapy discontinuation [JAAD 2016;74;127]. Caution must be exercised here as biologic agents have been reported to trigger GA.

Other treatments that have been employed for disseminated granuloma annulare include hydroxychloroquine, methotrexate (BJD Dec 2010), low dose dapsone, isotretinoin 0.5 mg/kg/day, SSKI, chlorambucil and CSA. In one review, all 6 patients treated with chloroquine improved, 5 of whom had failed previous treatment with hydroxychloroquine [JAAD 2017;76;765]. Narrow band UVB, and PUVA (both standard and bath0 have been reported useful. Phototherapy (5/week) with UVA-1 (340-400 nm) alone has been shown effective. Caution must be exercised here however as some cases of GA may be photo induced.

Six patients (5 with generalized GA) were treated with once monthly single doses of rifampicin 600 mg, ofloxacin 400 mg, and minocycline hydrochloride 100 mg until the skin cleared. All patients cleared after 4-8 pulses [Indian J Dermatol Venereol Leprol 2015;81:35-9]. (If ofloxacin is not available, ciprofloxacin 500 mg has been substituted.)

Treatment in Children

Low dose chloroquine 1.5-3.0 mg/kg/day or hydroxychloroquine 1-6 mg/kg/day cleared 6 children in one study [JAAD 1994;31;1064].

Additional Pictures

Annular GA
Granuloma annulare Granuloma annulare Granuloma annulare Granuloma annulare

Nodular GA on the knee and knuckle.
Nodular granuloma annulare Nodular granuloma annulare

Papular GA
Granuloma annulare Granuloma annulare

The acute form seen on the hands.
Granuloma annulare

Papular, umbilicated GA.
Papular, umbilicated granuloma annulare

GA in a photo distribution, also called actinic granuloma.
Granuloma annulare in a photo distribution. Also called actinic granuloma

RegionalDerm

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