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Granuloma Annulare PEGGY R Diagnosis and Management of Granuloma Annulare PEGGY R. CYR, M.D., Maine Medical Center, Portland, Maine Granuloma annulare is a benign, asymptomatic, self-limited papular eruption found in patients of all ages. The primary skin lesion usually is grouped papules in an enlarging annu- lar shape, with color ranging from flesh-colored to erythematous. The two most common types of granuloma annulare are localized, which typically is found on the lateral or dorsal surfaces of the hands and feet; and disseminated, which is widespread. Localized disease generally is self-limited and resolves within one to two years, whereas disseminated disease lasts longer. Because localized granuloma annulare is self-limited, no treatment other than reassurance may be necessary. There are no well-designed randomized controlled trials of the treatment of granuloma annulare. Treatment recommendations are based on the patho- physiology of the disease, expert opinion, and case reports only. Liquid nitrogen, injected steroids, or topical steroids under occlusion have been recommended for treatment of local- ized disease. Disseminated granuloma annulare may be treated with one of several systemic therapies such as dapsone, retinoids, niacinamide, antimalarials, psoralen plus ultraviolet A therapy, fumaric acid esters, tacrolimus, and pimecrolimus. Consultation with a dermatolo- gist is recommended because of the possible toxicities of these agents. (Am Fam Physician 2006;74:1729-34. Copyright © 2006 American Academy of Family Physicians.) ranuloma annulare is a benign annulare occurring in siblings, twins, and skin condition that typically con- successive generations have been reported.2 sists of grouped papules in an Seasonal peaks of granuloma annulare in the enlarging annular shape. Their spring and fall also have been described.3 G appearance ranges from flesh colored to The duration of the skin eruption varies. erythematous. The etiology is unknown, but In more than one half of patients, it resolves the disease usually is self-limited. Despite the spontaneously within two months to two dramatic appearance of this cutaneous erup- years. However, cases of disseminated gran- tion, it generally is asymptomatic; however, uloma annulare may last three to four years there may be some mild pruritus. The erup- or as long as 10 years. The eruption may tion can occur anywhere on the body, but it recur as well, with 40 percent of children occurs least often on the face and most often having recurrent lesions.4 on the lateral or dorsal surfaces of the hands and feet (Figure 1). Etiology The cause of granuloma annulare is Epidemiology unknown, but it has been reported to follow Granuloma annulare affects patients of all trauma, malignancy, viral infections (includ- ages. Most cases of localized granuloma ing human immunodeficiency virus [HIV], annulare are diagnosed in patients before Epstein-Barr virus, and herpes zoster), insect 30 years of age. Incidence is highest in women, bites, and tuberculosis skin tests.5 A delayed- with a ratio of 2.3 to 1.0 over men.1 Approxi- type hypersensitivity reaction and cell-medi- mately 15 percent of all patients with granu- ated immune response are hypothesized. loma annulare will have more than 10 lesions In one retrospective study, 12 percent of (i.e., disseminated granuloma annulare). patients with granuloma annulare had diabe- These patients are usually children younger tes mellitus.6 This study did not have a com- than 10 years or adults older than 40 years. parison group, so it is not clear whether the Although uncommon, cases of granuloma prevalence of diabetes mellitus was higher or Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2006 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Granuloma Annulare SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Localized granuloma annulare is self-limited and asymptomatic and usually does not require C 1 treatment. Options for treatment of localized granuloma annulare include liquid nitrogen, injected steroids, C 18 and topical steroids. Treatment for disseminated granuloma annulare should be undertaken in consultation with a C 19-27, 35, 36 dermatologist; options include dapsone, retinoids, antimalarial drugs, tacrolimus (Protopic), and pimecrolimus (Elidel). A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1666 or http://www.aafp.org/afpsort.xml. A B Figure 1. Localized granuloma annulare in a 25-year-old woman who has had the eruption on her (A) wrists and (B) ankles since age 17. The eruption spontaneously resolved but then recurred. lower than in the general population. Patients with dia- LOCALIZED betes mellitus had a higher incidence of chronic relaps- The localized form of granuloma annulare composes ing granuloma annulare than patients without diabetes. 75 percent of cases.11 Localized granuloma annulare A case-control study that included patients with and starts as a ring of small, firm, flesh-colored or red pap- without diabetes failed to reveal any statistically signifi- ules. As the condition progresses, there is some central cant correlation between granuloma annulare and type involution, and the ring of papules slowly increases from 2 diabetes.7 Some isolated cases of granuloma annulare 0.5 to 5.0 cm in diameter. The lesions may be isolated found in association with malignant neoplasm have been or coalesce into plaques. They are found on the lateral reported. In these cases, the malignant neoplasms were or dorsal surfaces of the hands and feet (Figure 2). More primarily lymphoma,8 but some were prostate cancer.9 than 50 percent of these patients will have spontaneous Granuloma annulare has occurred in all stages of HIV resolution within two years.5 infection as well.10 DISSEMINATED OR geNERALIZED Clinical Presentation Disseminated or generalized granuloma annulare is similar The four main clinical variants of granuloma annulare are: to the localized variant but is more widespread, having 10 localized, disseminated, subcutaneous, and perforating. or more lesions (Figure 3). The papules may fuse to form 1730 American Family Physician www.aafp.org/afp Volume 74, Number 10 ◆ November 15, 2006 Granuloma Annulare A B Figure 2. Localized granuloma annulare in a 27-year-old Figure 3. Disseminated granuloma annulare in a 62-year- woman with an asymptomatic eruption for one year on old woman on her (A) inner thigh and (B) elbows. The her left index finger. eruption was asymptomatic. annular lesions on the extremities, trunk, and neck. In limbs. The lesions are 1- to 4-mm papules with a central contrast to the localized form, these lesions may persist crust or scale with or without an umbilicated center. for three to four years or longer. Biopsy shows palisading granuloma with transepithe- lial elimination of degenerating collagen fibers.13 This SUBCUTANEOUS transepithelial elimination leads to the perforating desig- Subcutaneous granuloma annulare is diagnosed primar- nation. Twenty-five percent of patients report pruritus, ily in children two to five years of age. The lesions are and 25 percent report pain, mainly in lesions located on asymptomatic, rapidly growing subcutaneous nodules the palms.14 on the extremities, hands, scalp, buttocks, and pretibial and periorbital areas. The lesions may be solitary or in Differential Diagnosis clusters. Diagnosis is made with an excisional biopsy. Granuloma annulare can be mistaken for other common These lesions may resolve spontaneously or may recur annular skin conditions such as tinea corporis, pityriasis after excision. There have been no reports of progression rosea, nummular eczema, psoriasis, or erythema migrans to systemic illness.12 of Lyme disease. The lack of any surface changes to the skin is the key feature that distinguishes granuloma annu- PERFORATING lare from these other skin conditions. Specifically, there Perforating granuloma annulare is rare and occurs most is no scale or associated vesicles or pustules with granu- often in children and young adults. It is also more com- loma annulare; the skin surface is smooth. Less common mon in women. Perforating granuloma annulare can annular skin conditions (e.g., subacute cutaneous lupus have localized and generalized forms. The localized erythematosus, erythema annulare centrifugum) have form is found on the upper limbs and pelvis, and the associated scaling and can be ruled out. Urticaria also can generalized form, which is more common, is present present as annular plaques, but it is distinguished easily on the abdominal area, trunk, and upper and lower from granuloma annulare by its evanescent nature. November 15, 2006 ◆ Volume 74, Number 10 www.aafp.org/afp American Family Physician 1731 Granuloma Annulare A less common annular skin condition, sarcoidosis, Systemic therapy is required for disseminated granu- may present with reddish-brown to purplish infiltrated loma annulare, and many different treatments have been papules and plaques that commonly are found on the proposed (Table 117,19-37). The possible benefit of treat- face. Hansen’s disease (leprosy) also has erythematous ment, which
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