GRANULOMA ANNULARE (GA)

 A common self-limited, asymptomatic, chronic dermatosis of the dermis.

 Usually occurs in children and young adults.
 Consists of papules in an annular arrangement, commonly arising on the dorsa of the hands and feet,
elbows, and knees.
 Sometimes becomes generalized in distribution.
 Unless disfiguring, no treatment is an option.

EPIDEMIOLOGY
Common.
Age of Onset Children and young adults.
Sex Female:male ratio 2:1.

ETIOLOGY AND PATHOGENESIS

Unknown. An immunologically mediated necrotizing inflammation that surrounds blood vessels,
altering collagen and elastic tissue. Generalized GA may be associated with diabetes mellitus.

CLINICAL MANIFESTATION
Duration months to years. Usually asymptomatic and only cosmetic disfigurement.
Skin Lesions Firm, smooth, shiny, beaded, dermal papules and plaques, 1–5 cm annular, arciform
plaques with central depression (see Fig. 7-8A, B), skin-colored, violaceous, erythematous.
Subcutaneous GA (rare): painless, skin-colored, deep dermal or subcutaneous, solitary or multiple
nodules.
Distribution Isolated lesion, particularly on dorsum of hand, finger, or lower arm (Fig. 7-8 A ), multiple
lesions on extremities and trunk (Fig. 7-8 B ), or generalized (papular; older patients) (Fig. 7-8 C ).
Subcutaneous lesions are located near joints, palms and soles, buttocks.

Variants
• Perforating lesions are very rare and mostly on the hands; central umbilication followed by crusting
and ulceration; this type was associated with diabetes in one series.
• May rarely involve fascia and tendons, causing sclerosis.
• Generalized GA: in this form a search for diabetes mellitus should be made.

DIFFERENTIAL DIAGNOSIS
GA is important because of its similarity to more serious conditions.
Papular Lesions and Plaques Necrobiosis lipoidica, papular sarcoid, lichen planus, lymphocytic
infiltrate of Jessner.
Subcutaneous Nodules Rheumatoid nodules: confusion can occur because of the similar pathology
of GA and rheumatic nodule or rheumatoid nodules. Also subcutaneous fungal infections such as
sporotrichosis and NTM (M. marinum).
Annular Lesions Tinea, erythema migrans, sarcoid, lichen planus.

LABORATORY EXAMINATION
Dermatopathology Foci of chronic inflammatory and histiocytic infiltrations in superficial and mid-
dermis, with necrobiosis of connective tissue surrounded by a wall of palisading histiocytes and
multinucleated giant cells.

COURSE
The disease disappears in 75% of patients in 2 years. Recurrences are common (40%), but they also
disappear.
MANAGEMENT
GA is a local skin disorder and not a marker for internal disease, and spontaneous remission is the rule.
No treatment is an option if the lesions are not disfiguring . Lesions may resolve after biopsy.
Topical Therapy Topical Glucocorticoids - Applied under plastic occlusion or hydrocolloid.
Intralesional Triamcinolone 3 mg/mL into lesions is very effective.
Cryospray Superficial lesions respond to liquid nitrogen, but atrophy may occur.
PUVA Photochemotherapy Effective in generalized GA.
Systemic Glucocorticoids Effective in generalized GA, but recurrences common.