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CASE REPORT
Year : 2017  |  Volume : 37  |  Issue : 2  |  Page : 79-81

Generalized papular granuloma annulare


Department of Skin and Venereal Disease, Shree Krishna Hospital, Pramukhswami Medical College, Karamsad, Gujarat, India

Date of Submission16-Feb-2017
Date of Acceptance17-Feb-2017
Date of Web Publication4-Aug-2017

Correspondence Address:
Rita V Vora
(Dermatology, Venerology and Leprosy), Opd-111, Department of Skin and Venereal Disease, Shree Krishna Hospital, Pramukhswami Medical College, Karamsad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejdv.ejdv_5_17

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  Abstract 


Granuloma annulare is a benign skin condition that typically consists of grouped papules in an enlarging annular shape. It affects patients of all ages and is generally asymptomatic. The lesions rarely occur on the palms, soles, face, and mucous membranes. In this study, we present the case of a 47-year-old woman with lesions over her chest, bilateral forearms, and upper back, diagnosed as having generalized papular granuloma annulare.

Keywords: annular lesions, necrobiosis, papular granuloma annulare


How to cite this article:
Gandhi SS, Singhal RR, Sheth NK, Vora RV. Generalized papular granuloma annulare. Egypt J Dermatol Venerol 2017;37:79-81

How to cite this URL:
Gandhi SS, Singhal RR, Sheth NK, Vora RV. Generalized papular granuloma annulare. Egypt J Dermatol Venerol [serial online] 2017 [cited 2017 Sep 25];37:79-81. Available from: http://www.ejdv.eg.net/text.asp?2017/37/2/79/212102




  Introduction Top


Granuloma annulare (GA) is a benign, self-limited dermatosis of unknown cause, characterized by necrobiotic dermal papules that often assume an annular configuration. Clinically, GA can be divided into distinct types such as localized, generalized, subcutaneous, perforating, and papular [1],[2]. GA can occur at any age, with a slight female predominance [3]. Most of the cases occur before the age of 30 and are sporadic, although occasional familial cases have been described. The lesions are symmetrical and asymptomatic and rarely involve the palms, soles, face, and mucous membranes.


  Case report Top


A 47-year-old woman presented with skin-colored lesions over the right dorsum of her hand, which later progressed to involve her chest and upper back. History of aggravation on photo exposure was present. There was no history of itching, burning, or discharge from the lesions. There was no history of drug or food allergy. She had no past history of any major illnesses including pulmonary tuberculosis. No other systemic complaints were present. On examination, multiple, discrete, skin-colored papules were present over the bilateral upper limbs ([Figure 1]a and [Figure 1]b), abdomen, and upper back with a few annular plaques over the upper back ([Figure 2]a and [Figure 2]b). Her blood count, erythrocyte sedimentation rate, liver and kidney function tests, and blood sugars, cholesterol fractions, triglycerides, and thyroid-stimulating hormone levels were normal. Antinuclear antibodies, anti-HCV (antihepatitis C virus antibodies), HBsAg (surface antigen of hepatitis B virus), anti-HBc IgG (antibodies of IgG fraction produced against antigens of the nucleocapsid of hepatitis B virus), and anti-HIV I and II (antibodies against the HIV type 1 and 2) were not reactive. Biopsy from one of the lesions showed presence of palisades of histiocytes, giant cells, and perivascular infiltrate of lymphocytes in the dermis. However, mucin was not present, and the epidermis was remarkably suggestive of GA of the arm ([Figure 3]a and [Figure 3]b). The patient was started on mild topical steroids and oral pentoxifylline, and showed little improvement.
Figure 1 (a, b) Multiple, discrete, skin-colored papules present over the right forearm and the left forearm, respectively.

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Figure 2 (a, b) Annular plaques over the abdomen and the upper back, respectively.

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Figure 3 (a, b) Biopsy from one of the lesions showing presence of palisades of histiocytes, giant cells, and perivascular infiltrate of lymphocytes in the dermis. Hematoxylin and eosin, ×10 and ×40 magnification.

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  Discussion Top


GA is a benign skin condition that typically consists of grouped papules in an enlarging annular shape. Their appearance ranges from flesh-colored to erythematous. The etiology is unknown, but the disease is usually self-limiting. It generally is asymptomatic; however, there may be mild pruritus. The eruption can occur anywhere on the body, but it occurs least often on the face and most often on the lateral or dorsal surfaces of the hands and feet. GA affects patients of all ages. Most cases of localized GA are diagnosed in patients before 30 years of age. Incidence is highest in women, with a ratio of 2.3 to 1.0 over men [3]. Approximately 15% of all patients with GA will have more than 10 lesions (i.e. disseminated GA). These patients are usually children younger than 10 years or adults older than 40 years. Although uncommon, cases of GA occurring in siblings, twins, and successive generations have been reported [4]. Seasonal peaks of GA in spring and fall have also been described [5]. The duration of the skin eruption varies. In more than one-half of patients, it resolves spontaneously within 2 months to 2 years. However, cases of disseminated GA may last 3–4 years or as long as 10 years. The eruption may recur as well, with 40% of children having recurrent lesions [6].

The causes for GA are unknown, but it has been reported to follow trauma, malignancy, viral infections (including HIV, Epstein–Barr virus, and herpes zoster), insect bites, and tuberculosis skin tests [7]. A delayed-type hypersensitivity reaction and cell-mediated immune response are hypothesized. In one retrospective study, 12% of patients with GA had diabetes mellitus [5]. The primary skin lesion usually is grouped papules in an enlarging annular shape, with color ranging from flesh-colored to erythematous. The main clinical variants of GA are localized, disseminated, subcutaneous, papular, and perforating. Localized disease generally is self-limited and resolves within 1–2 years, whereas disseminated disease lasts longer.

GA can be mistaken for other common annular skin conditions such as tinea corporis, pityriasis rosea, nummular eczema, psoriasis, or erythema migrans of Lyme disease. The lack of any surface changes to the skin is the key feature that distinguishes GA from these other skin conditions. Specifically, there is no scale or associated vesicles or pustules with GA; the skin surface is smooth. Less common annular skin conditions such as subacute cutaneous lupus erythematosus and erythema annulare centrifugum have associated scaling and can be ruled out. Urticaria also can present as annular plaques, but it is distinguished easily from GA by its evanescent nature. Often, a diagnosis can be made without a punch biopsy, but in clinically confusing situations it may be helpful, especially with the subcutaneous variant of GA. Histopathology shows normal epidermis, characteristic focal degeneration of collagen with reactive inflammation, and fibrosis [8]. The degenerated dermis is surrounded by palisading granuloma containing histiocytes, fibrocytes, and lymphocytes.

Topical therapy includes corticosteroids, tacrolimus, pimecrolimus, and vitamin E. Systemic therapy is necessary for the treatment of disseminated GA. It includes dapsone, retinoids, antimalarials, pentoxifylline, nicotinamide, dipyridamole, and infliximab. Phototherapy may also be helpful. The possible benefits of treatment, which is uncertain because of lack of clinical trials, must be balanced against the risk of toxicity presented by most of these treatments [9].

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prendiville JS. Granuloma annulare. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick’s dermatology in general medicine. New York: McGraw-Hill; 2008. pp. 369–373.  Back to cited text no. 1
    
2.
Odom RB, James WD, Berger TG. Andrews’ diseases of the skin. 9th ed. Philadelphia: WB Saunders; 2000.  Back to cited text no. 2
    
3.
Dahl MV. Granuloma annulare. In: Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austin KF, editors. Dermatology in general medicine. 6th ed. New York: McGraw-Hill; 2003. pp. 980–984.  Back to cited text no. 3
    
4.
Friedman SJ, Winkelmann RK. Familial granuloma annulare. Report of two cases and review of the literature. J Am Acad Dermatol 1987; 16 (Part 1):600–605.  Back to cited text no. 4
    
5.
McLelland J, Young S, Marks JM, Lawrence CM. Seasonally recurrent granuloma annulare of the elbows. Clin Exp Dermatol 1991; 16:129–130.  Back to cited text no. 5
    
6.
Barron DF, Cootauco MH, Cohen BA. Granuloma annulare. A clinical review. Lippincotts Prim Care Pract 1997; 1:33–39.  Back to cited text no. 6
    
7.
Smith MD, Downie JB, DiCostanzo D. Granuloma annulare. Int J Dermatol 1997; 36:326–333.  Back to cited text no. 7
    
8.
Cyr PR. Diagnosis and management of granuloma annulare, Am Fam Physician 2006; 74:1729–1734.  Back to cited text no. 8
    
9.
Dornelles SIT, Poziomczyk CS, Boff A, Koche B, Dornelles MA, Richter GK. Generalized perforating granuloma annulare. An Bras Dermatol 2011; 86: 327–331.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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