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Granuloma annulare is a benign, usually self-limited granulomatous disease of the dermis and subcutaneous tissue. Several distinct subtypes have been recognized, namely localized granuloma annulare, generalized or disseminated granuloma annulare, subcutaneous granuloma annulare, papular granuloma annulare, interstitial or patch granuloma annulare, and perforating granuloma annulare. Localized granuloma annulare is the most common form in children and comprises 75% of cases. Clinically, the condition is characterized by asymptomatic, flesh-colored or erythematous-brown papules, frequently arranged in a ring or annular pattern on the distal extremities. It is estimated that 0.1 to 0.4% of new patients attending dermatologic clinics have granuloma annulare. Most cases of granuloma annulare occur before the age of 30 years. A delayed hypersensitivity and cell-mediated immune response to an antigen contributes to the pathogenesis. Histologic examination of the lesion shows central collagen degeneration and mucin deposition surrounded peripherally by palisading histiocytes and inflammatory cells. Most cases of granuloma annulare are asymptomatic and self-limited; and reassurance is often sufficient. Treatment is mainly for cosmetic purposes and various modalities of treatment options are discussed.
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International Journal of Pediatrics and Child Health, 2013, 1, 15-18 15
© 2013 Savvy Science Publisher
Granuloma Annulare
Alexander K.C. Leung1,*, Benjamin Barankin2 and Kam Lun Hon3
1Department of Pediatrics, University of Calgary, Pediatric Consultant, Alberta Children's Hospital, Canada
2Toronto Dermatology Centre, Canada
3Department of Paediatrics, Chinese University of Hong Kong, China
Abstract: Granuloma annulare is a benign, usually self-limited granulomatous disease of the dermis and subcutaneous
tissue. Several distinct subtypes have been recognized, namely localized granuloma annulare, generalized or
disseminated granuloma annulare, subcutaneous granuloma annulare, papular granuloma annulare, interstitial or patch
granuloma annulare, and perforating granuloma annulare. Localized granuloma annulare is the most common form in
children and comprises 75% of cases. Clinically, the condition is characterized by asymptomatic, flesh-colored or
erythematous-brown papules, frequently arranged in a ring or annular pattern on the distal extremities. It is estimated
that 0.1 to 0.4% of new patients attending dermatologic clinics have granuloma annulare. Most cases of granuloma
annulare occur before the age of 30 years. A delayed hypersensitivity and cell-mediated immune response to an antigen
contributes to the pathogenesis. Histologic examination of the lesion shows central collagen degeneration and mucin
deposition surrounded peripherally by palisading histiocytes and inflammatory cells. Most cases of granuloma annulare
are asymptomatic and self-limited; and reassurance is often sufficient. Treatment is mainly for cosmetic purposes and
various modalities of treatment options are discussed.
Keywords: Granuloma annulare, ring/annular pattern, collagen degeneration, mucin, palisading histiocytes, benign.
INTRODUCTION
Granuloma annulare is a benign, usually self-limited
granulomatous disease of the dermis and
subcutaneous tissue [1]. The condition was first
described in 1895 by Colcott-Fox who reported an 11-
year-old girl with a “ring eruption of the fingers” [2]. The
term “granuloma annulare” was coined by Radcliff-
Crocker in 1902 [3]. Clinically, the condition is
characterized by asymptomatic, flesh-colored or
erythematous-brown papules, frequently arranged in a
ring or annular pattern on the distal extremities [4].
Several distinct subtypes have been recognized,
namely localized granuloma annulare, generalized or
disseminated granuloma annulare, subcutaneous
granuloma annulare, papular granuloma annulare,
interstitial or patch granuloma annulare, and perforating
granuloma annulare [1, 5].
PREVALENCE
Although the point prevalence of granuloma
annulare in the community is not known, it is estimated
that 0.1 to 0.4% of new patients attending dermatologic
clinics have granuloma annulare [6]. Most cases of
granuloma annulare occur before the age of 30 years
[7]. The female to male ratio is approximately 2:1 [7].
*Address correspondence to this author at the #200, 233 – 16th Avenue NW,
Calgary, Alberta, T2M 0H5, Canada; Tel/Fax: (403) 230-3322;
E-mail: aleung@ucalgary.ca
ETIOLOGY
In the majority of cases, the etiology is not known.
Occasionally, granuloma annulare has been reported
to follow trauma, insect bites, tuberculin skin tests,
immunizations (e.g., hepatitis B, diphtheria-tetanus,
bacillus Calmette-Guérin), viral infections (e.g., herpes
zoster, Epstein Barr virus, hepatitis B, hepatitis C,
human immunodeficiency virus), medications (e.g.,
amlodipine, allopurinol, diclofenac), diabetes mellitus,
autoimmune thyroiditis, rheumatoid arthritis, and
malignancy [6-13]. These associations have been
reported mainly in adult populations [6]. Familial cases
of granuloma annulare have also been reported [8, 14].
Certain human leukocyte antigen phenotypes (e.g.,
HLA-A29, HLA-A31, HLA-B8, HLA-B14, HLA-B15,
HLA-B35) occur with increasing frequency in patients
with granuloma annulare [8].
PATHOGENESIS
The presence of T-helper cells with histiocytes in
the inflammatory infiltrate in granuloma annulare
suggests that a delayed hypersensitivity and cell-
mediated immune response to an antigen contribute to
the pathogenesis [7, 8].
HISTOPATHOLOGY
Histologic examination of a classic lesion shows
central collagen degeneration and mucin deposition
surrounded peripherally by palisading histiocytes and
inflammatory cells [1, 8, 15]. The presence of mucin is
16 International Journal of Pediatrics and Child Health, 2013 Vol. 1, No. 1 Leung et al.
a key histological feature that helps to distinguish
granuloma annulare from other non-infectious
granulomatous diseases [13]. In the interstitial variant,
the dermis contains a focal interstitial infiltrate of
histiocytes and giant cells [16].
CLINICAL MANIFESTATIONS
Localized granuloma annulare is the most common
form in children and comprises 75% of cases [6, 7, 17].
The lesion starts as a ring of small, smooth, firm,
asymptomatic, erythematous, violaceous, brown or
skin-colored papules [7, 8]. As the condition
progresses, there is some central involution [7]. The
ring of papules often becomes coalescent to form an
annular plaque. The lesion gradually enlarges to
usually less than 5 cm in diameter. Typically, lesions
are solitary or few in number [15]. Sites of predilection
include the lateral or dorsal surfaces of the hands and
feet (Figure 1) [7]. Involvement of the palms is rare, but
has been reported [18]. In most patients, the condition
is often asymptomatic [19] Rarely, it can be mildly
pruritic [7].
Figure 1: Classic violaceous lesion of granuloma annulare on
the lateral aspect of the left ankle.
Generalized granuloma annulare occurs in
approximately 15% of patients with granuloma
annulare [20]. The condition manifests as numerous (at
least 10, often hundreds to thousands) small,
asymptomatic, erythematous, violaceous, brown or
skin-colored papules [21]. Lesions are symmetrically
distributed on the trunk, extremities, and neck [21].
Generalized granuloma annulare has a bimodal peak
age of presentation, in the first decade of life and
between the fourth and sixth decades of life [17]. It has
been associated with diabetes mellitus [22].
Subcutaneous granuloma annulare is diagnosed
primarily in children and young adults [23]. The lesion
usually presents as a painless flesh-colored
subcutaneous nodule with no inflammatory appearance
at the skin surface [1, 23]. Sites of predilection include
the pretibial areas, feet, forearms, hands, fingers,
scalp, and forehead [5, 6, 23]. It rarely occurs in the
periocular area. When it does occur, the annular
pattern is often absent [24].
Papular granuloma annulare presents as
asymptomatic, skin-colored or hypopigmented papules
[25]. The papules usually measure 1 to 3 mm in
diameter and the consistency is firm. Papular
granuloma annulare most commonly affect children,
predominately on the dorsal surface of the hands [25].
Interstitial granuloma annulare manifests as
asymptomatic erythematous or light brown patches
without scales or papules that may or may not have an
annular configuration [21]. Sites of predilection include
the trunk and extremities [21].
Perforating granuloma annulare is rare. It presents
with papules that are 1 to 5 mm in diameter and occur
more often on the dorsal aspects of the hands and feet
[21, 22]. Characteristically, these papules have central
umbilication or crusts and are well demarcated [21].
Perforation occurs in the central portion of the lesion
through which mucoid material consisting of
degenerated collagen is eliminated [13, 22]. Itching
occurs in up to 25% of cases, especially when there
are lesions on palms [22].
LABORATORY INVESTIGATIONS
Children with granuloma annulare are generally
healthy and no laboratory investigations are usually
necessary [1]. Nevertheless, a recent case-control
study shows that adult patients with granuloma
annulare are more likely to develop dyslipidemia (odds
ratio: 4.04; 95% confidence interval: 2.53-6.46) [26]. It
has been suggested that it is reasonable to test for
fasting serum lipid levels in adult patients with
granuloma annulare, especially if there are other risk
factors for dyslipidemia [13, 27]. Patients with
generalized granuloma annulare should be checked for
the presence of diabetes mellitus.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
The diagnosis is mainly clinical. The differential
diagnosis of localized granuloma annulare includes
tinea corporis, pityriasis rosea, pityriasis rotunda,
erythema annulare centrifugum, nummular eczema,
discoid lupus erythematosus, psoriasis, sarcoidosis,
Granuloma Annulare International Journal of Pediatrics and Child Health, 2013 Vol. 1, No. 1 17
mycosis fungoides (plaque stage), mastocytoma,
dermatofibroma, necrobiosis lipoidica, morphea,
hypertrophic lichen planus, or erythema chronicum
migrans [7, 8, 28]. Subcutaneous granuloma annulare
has to be differentiated from sarcoidosis, rheumatoid
nodule, and panniculitis [13]. The differential diagnosis
of generalized granuloma annulare includes eruptive
xanthoma, lichen nitidus, lichen scrofulosorum,
sarcoidosis, interstitial granulomatous dermatitis, non-X
histiocytosis, and papular xanthoma [9, 29, 30]. On the
other hand, perforating granuloma annulare may mimic
elastosis perforans serpiginosa, perforating
collagenosis, perforating folliculitis, and perforating
sarcoidosis [31]. The clinical features of granuloma
annulare are so distinct that usually there is little
difficulty in diagnosis for an experienced physician. In
particular, lack of symptoms, scaling or associated
vesicles helps to differentiate granuloma annulare from
most other skin conditions. If the diagnosis is in doubt,
a biopsy should be considered.
COMPLICATIONS
In the adult population, granuloma annulare is
associated with diabetes mellitus in 16-19% of cases
[22]. Dyslipidemia is more common in patients with
granuloma annulare [26]. Rarely, granuloma annulare
may be complicated by nerve involvement as a result
of granulomatous inflammation surrounding cutaneous
nerves and perineural infiltrates of histiocytes in the
dermis [16].
PROGNOSIS
Localized granuloma annulare usually resolves
without scarring within one to two years [15, 32]. Other
forms may persist for a few years or longer [7]. Shorter
duration is associated with younger age and recent
onset [23]. The recurrence rate is approximately 40%
[15].
MANAGEMENT
Most cases of granuloma annulare are
asymptomatic and self-limited, treatment is usually not
required other than reassurance [6, 15]. For patients
who insist on treatment for cosmetic reasons, options
include topical or intralesional corticosteroids,
imiquimod cream, topical calcineurin inhibitors
(tacrolimus, pimecrolimus), cryotherapy, and pulsed
dye laser [7, 15, 34-36]. Surgical removal is an option
for the nodular lesion seen in subcutaneous granuloma
annulare [32]. Systemic therapy may be required for
generalized granuloma annulare which is often
resistant to treatment [15]. Interventions that have been
used with varying degrees of success include oral
corticosteroids, fumaric acid esters, dapsone,
isotretinoin, hydroxychloroquine, methotrexate,
cyclosporine, niacinamide, calcitriol, vitamin E, tumor
necrosis factor (TNF)- inhibitors (adalimumab and
infliximab), and several variants of phototherapy [7, 13,
19, 20, 37-41].
REFERENCES
[1] Hacihamdiolu B, Özcan A, Kalman S. Subcutaneous
granuloma annulare in a child: a case report. Clin Pediatr
2008; 47: 306-308.
http://dx.doi.org/10.1177/0009922807308742
[2] Colcott-Fox T. Ringed eruption of the fingers. Br J Dermatol
1895; 7: 91-95.
[3] Radcliff-Crocker H. Granuloma annulare. Br J Dermatol
1902; 14: 1-9.
http://dx.doi.org/10.1111/j.1365-2133.1902.tb16407.x
[4] Marcus DV, Mahmond BH, Hamzavi IH. Granuloma annulare
treated with rifampin, ofloxacin, and minocycline combination
therapy. Arch Dermatol 2009; 145: 787-89.
http://dx.doi.org/10.1001/archdermatol.2009.55
[5] Canado C, Vale FR, Bacchi CE. Subcutaneous (deep)
granuloma annulare in children: a possible mimicker of
epithelioid sarcoma. Fetal Pediatr Pathol 2007; 26: 33-39.
http://dx.doi.org/10.1080/15513810701394678
[6] Kennedy CT. Granuloma annulare. In: Harper J, Oranje A,
Prose N. (eds). Textbook of Pediatric Dermatology. Oxford:
Blackwell Publishing 2006; pp. 889-900.
[7] Cyr PR. Diagnosis and management of granuloma annulare.
Am Fam Physician 2006; 74: 1729-34.
[8] Kovich O, Burgin S. Generalized granuloma annulare.
Dermatol Online J 2005; 11(4): 23.
[9] Lee SW, Cheong SH, Byun JY, et al. Generalized granuloma
annulare in infancy following bacillus Calmette-Guerin
vaccination. Ann Dermatol 2011; 23(Suppl 3): S319-S321.
http://dx.doi.org/10.5021/ad.2011.23.S3.S319
[10] Park JY, Park JE, Kim YC. Generalized granuloma annulare
possibly associated with acute Epstein-Barr virus infection.
Eur J Dermatol 2011; 21: 788-89.
[11] Spicuzza L, Salafia S, Capizzi A, et al. Granuloma annulare
as first clinical manifestation of diabetes mellitus in children:
a case report. Diabetes Res Clin Pract 2012; 95: e55-e57.
http://dx.doi.org/10.1016/j.diabres.2011.11.015
[12] Spring P, Vernez M, Maniu CM, et al. Localized interstitial
granuloma annulare induced by subcutaneous injections for
desensitization. Dermatol Online J 2013; 19(6): 15.
[13] Thornsberry LA, English JC III. Etiology, diagnosis, and
therapeutic management of granuloma annulare: an update.
Am J Clin Dermatol 2013; 14: 279-90.
http://dx.doi.org/10.1007/s40257-013-0029-5
[14] Abrusci V, Weiss E, Planas G. Familial generalized
perforating granuloma annulare. Int J Dermatol 1988; 27:
126-27.
http://dx.doi.org/10.1111/j.1365-4362.1988.tb01292.x
[15] Goucha S, Khaled A, Kharfi M, et al. Granuloma annulare. G
Ital Dermatol Venereol 2008; 143: 359-63.
[16] Longmire M, DiCaudo DJ, Dahl MV. Nerve involvement in
granuloma annulare. J Cutan Med Surg 2012; 16: 428-32.
[17] Gass JK, Todd PM, Rytina E. Generalized granuloma
annulare in a photosensitive distribution resolving with
scarring and milia formation. Clin Exp Dermatol 2009; 34:
e53-e55.
http://dx.doi.org/10.1111/j.1365-2230.2008.03183.x
18 International Journal of Pediatrics and Child Health, 2013 Vol. 1, No. 1 Leung et al.
[18] Gutte R, Khopkar U, Kothari D. Granuloma annulare on the
palms: a clinicopathological study of seven cases. Indian J
Dermatol Venereol Leprol 2012; 78: 468-74.
http://dx.doi.org/10.4103/0378-6323.98078
[19] Boyd AS, Boyd AS. Granuloma annulare responsive to oral
calcitriol. Int J Dermatol 2012; 51: 115-24.
http://dx.doi.org/10.1111/j.1365-4632.2010.04510.x
[20] Torres T, Almeida TP, Alves R, et al. Treatment of
recalcitrant generalized granuloma annulare with
adalimumab. J Drug Dermatol 2011; 10: 1466-68.
[21] Victor FC, Mengden S. Granuloma annulare, patch type.
Dermatol Online J 2008; 14(5): 21.
[22] Dornelles SI, Poziomczyk CS, Boff A. Generalized
perforating granuloma annulare. An Bras Dermatol 2011; 86:
327-31.
http://dx.doi.org/10.1590/S0365-05962011000200016
[23] Requena L, Fernández-Figueras MT. Subcutaneous
granuloma annulare. Semin Cutan Med Surg 2007; 26: 96-
99.
http://dx.doi.org/10.1016/j.sder.2007.02.006
[24] De Becker, Summers CG, Kaye V, et al. Periocular
granuloma annulare in four children. J AAPOS 2010; 14:
280-82.
http://dx.doi.org/10.1016/j.jaapos.2010.02.004
[25] Cho E, Cho SH, Lee JD. Unusual presentations of popular
umbilicated granuloma annulare. J Dermatol 2011; 38: 402-
404.
http://dx.doi.org/10.1111/j.1346-8138.2010.00977.x
[26] Wu W, Robinson-Bostom L, Kokkotpou E, et al. Dyslipidemia
in granuloma annulare: a case-control study. Arch Dermatol
2012; 148: 1131-36.
http://dx.doi.org/10.1001/archdermatol.2012.1381
[27] Dahl MV. Testing lipid levels in granuloma annulare. Arch
Dermatol 2012; 148: 1136-37.
http://dx.doi.org/10.1001/archdermatol.2012.1503
[28] Leung L. Ring-like lesions on the hand: a case study. Aust
Fam Physician 2012; 41: 51-52.
[29] Orkwis HK, Cattell C, Ghaferi J. Multicentric
reticulohistiocytosis presenting as granuloma annulare. J
Drugs Dermatol 2012; 11: 1509-10.
[30] Phuardchantuk R, Pattanprichakul P, Sitthinamsuwan P,
et al. Generalized granuloma annulare presenting with
lesions resembling eruptive xanthoma. J Med Assoc Thai
2013; 96: 117-20.
[31] Ingraffea A, Vinovrski T, Zhou LH. What is your diagnosis?
Perforating granuloma annulare. Cutis 2011; 87: 116: 123-
24.
[32] Leung AK. Granuloma annulare. In: Leung AK, ed. Common
Problems in Ambulatory Pediatrics: Specific Clinical
Problems, volume 2. New York: Nova Science Publishers,
Inc., 2011; pp. 263-266.
[33] Wallet-Faber N, Farhi D, Gorin I, et al. Outcome of
granuloma annulare: shorter duration is associated with
younger age and recent onset. J Eur Acad Dermatol
Venereol 2029; 24: 103-104.
http://dx.doi.org/10.1111/j.1468-3083.2009.03343.x
[34] Gomez-Moyano E, Vera-Cassano A, Martinez S, et al.
Periorbital granuloma annulare successfully treated with
tacrolimus 0.1% ointment. Int J Dermatol [Epub ahead of
print].
[35] Passeron T, Fusade T, Vabres P, et al. Treatment of
granuloma annulare with the 595-nm pulsed dye laser, a
multicentre retrospective study with long-term follow-up. J
Eur Acad Dermatol Venereol 2013; 27: 785-88.
http://dx.doi.org/10.1111/j.1468-3083.2011.04402.x
[36] Sliger BN, Burk CJ, Alvarez-Connelly E. Treatment of
granuloma annulare with the 595 nm pulsed dye laser in a
pediatric patient. Pediatr Dermatol 2008; 25: 196-97.
http://dx.doi.org/10.1111/j.1525-1470.2008.00632.x
[37] Acharya U. Successful treatment of disseminated granuloma
annulare with oral fumaric acid esters. Int J Dermatol 2013;
52: 633-34.
http://dx.doi.org/10.1111/j.1365-4632.2011.04930.x
[38] Kozic H, Webster GF. Treatment of widespread granuloma
annulare with adalimumab: a case report. J Clin Aesthet
Dermatol 2011; 4: 42-43.
[39] Plotner AN, Mutasim DF. Successful treatment of
disseminated granuloma annulare with methotrexate. Br J
Dermatol 2010; 163: 1123-24.
http://dx.doi.org/10.1111/j.1365-2133.2010.09923.x
[40] Poppe H, Poppe LM, Goebeler M, et al. Treatment of
disseminated granuloma annulare with oral vitamin E:
‘Primum nil nocere’. Dermatology 2013; 227: 83-88.
http://dx.doi.org/10.1159/000353528
[41] Wollina U, Langner D. Treatment of disseminated granuloma
annulare recalcitrant to topical therapy: a retrospective 10-
year analysis with comparison of photochemotherapy alone
versus photochemotherapy plus oral fumaric acid esters. J
Eur Acad Dermatol Venereol 2012; 26: 1319-27.
http://dx.doi.org/10.1111/j.1468-3083.2011.04320.x
Received on 28-10-2013 Accepted on 01-11-2013 Published on 26-12-2013
© 2013 Leung et al.; Licensee Savvy Science Publisher.
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Background: Nerve involvement developed in a patient with granuloma annulare, as evidenced by a perineural infiltrate of histiocytes in the dermis. The histopathologic pattern was suggestive of leprosy. No mycobacteria were observed, and neurologic testing was normal. Objective: To determine whether inflammation of the nerves or perineural tissue is common in granuloma annulare, we studied the cutaneous nerves in skin biopsy specimens from 14 patients with granuloma annulare. Methods: Sections were stained with hematoxylin-eosin to highlight inflammatory cells and with S-100 to identify cutaneous nerves. Results: No inflammation around nerves was found in 12 specimens, abutting granulomatous inflammation was found in 1 specimen, and enveloping granulomatous inflammation was found in 1 specimen. No nerves were infiltrated by inflammatory cells. Conclusion: Perineural granulomatous inflammation resembling the perineural infiltrate of leprosy appears to be an uncommon characteristic of granuloma annulare. Clinical correlation and acid-fast stains can assist in establishing the correct diagnosis.