A Case of Perforating Granuloma Annulare Dustin Mullens, DO Affiliated Dermatology, Scottsdale, AZ 85255 Introduction Case Report Discussion Granuloma annulare (GA) is a chronic skin condition that presents as Granuloma annulare (GA) is a granulomatous inflammatory disorder of the discolored plaques in a ring formation. This skin condition is seen in 0.1-0.4% skin not uncommonly seen. Perforating granuloma annulare (PGA) is a rare of patients presenting to dermatology offices and is 2.5 times more common in clinical variant occurring in up to 5% of patients with GA, first described in females. The exact pathogenesis is unknown, however, inciting factors such as 1971 by Owens and Freeman. PGA has a chronic course with predilection trauma, insect bites, tuberculosis skin tests, vaccines, sun exposure, and for the extremities or less commonly generalized to involve the trunk and infections have been implicated. The most common histopathological findings extremities. The primary lesion is a small umbilicated papule, scale-crust or include dermal lymphohistiocytic infiltration and degenerated collagen. focal ulceration primarily on the dorsal hands and fingers and histologically Granuloma annulare has been associated with numerous disorders including exhibits transepidermal elimination of degenerating collagen. diabetes mellitus, dyslipidemia, thyroid disorder, malignancy, and HIV infection. The five identified variants of granuloma annulare include localized GA, Two punch biopsies showed mucin deposition in the centers of the generalized GA, subcutaneous GA, patch GA, and perforating GA. The most granulomatous foci, although not as much in most cases of granuloma common subtype, localized GA, is a non-scaly, erythematous annular plaque annulare. Some transepidermal elimination evidence was observed, which on the distal extremities seen in the first three decades of life. Generalized GA Figure 1. Right Palmar Hand Figure 4. Right Antecubital Fossa histologically correlates with the crusted areas seen clinically. Atypical accounts for about 15% of all GA cases, is most common in the 4th through 7th presentation of necrobiosis lipoidica was also considered as a possibility. decades, and consists of numerous erythematous papules and plaques found However, most cases of this variant are now considered to be annular on the trunk and extremities. Subcutaneous GA is the most common type of elastolytic giant cell granuloma (AEGCG), also known as actinic granuloma, GA found in children. Perforating GA (PGA) is most often found in children or which is in turn regarded by many as a variant of granuloma annulare. The young adults with an increased prevalence in Hawaii. PGA presents as sparing of elastic fibers in an elastic van Giesen stain is against necrobiosis erythematous papules that can be either localized to the extremities or lipoidica. widespread and may develop into umbilicated papules with clear-to-white discharge. The pathology of PGA consists of trans-epidermal elimination of Secondary syphilis was treated with doxycycline 100mg by mouth twice mucinous degenerated collagen surrounded by palisading lymphohistoiocytic daily for 14 days. The patient was treated with topical Clobetasol 0.05% granulomas. ointment twice daily to the skin lesions until flat and no longer erythematous. Treatment of the localized form of PGA using intralesional Case Report corticosteroids or topical high-potency corticosteroids may also be used. Figure 2. Right Palmar Hand, 2X: Punch biopsy of acral skin Figure 5. Right Antecubital Fossa, 4X: Punch biopsy of skin A 60 year-old Caucasian male with past medical history of diabetes and extending into the superficial subcutaneous adipose tissue. with a dense palisaded granulomatous infiltrate extending Topical imiquimod, topical calcineurininhibitors pimecrolimus and hypertension treated with lisinopril who presented with a 6-week history of There is a central dilated epidermal channel filled with a into the deep reticular dermis. There is an associated tacrolimus, cryotherapy, and simple excision have been reported keratin plug. The dermis contains a lymphohistiocytic perivascular lymphocytic inflammatory infiltrate in the multiple skin lesions on the left and right arms. Patient denied any systemic inflammatory infiltrate arranged in a granulomatous pattern. superficial portion of thisimage. treatments for PGA. The treatment of perforating granuloma annulare is symptoms such as fever, chills, night sweats or weight change. Patient reported often unsuccessful. the lesions were tender when palpated. He denied any previous treatment. References Laboratory Tests: 1.Owens DW, Freeman RG. Perforating granuloma annulare. Arch Dermatol. 1971; 103:64-67 Glucose 340 mg/dL 2.Penas PF, Jones-Caballero M, Fraga J, et al. Perforating granuloma annulare. Int J Triglyceride 256 mg/dL Dermatol. 1997;36:340-8 RPR Screen Reactive 3.Igraffea A, Vinovrski T, Zhou LH. What is your diagnosis? Perforating granuloma RPR Titer 1:32 annulare. Cutis 2011, 87, 123-124 Treponema pallidum Antibody-PAReactive 4.Thornsberry LA, English JC. 3rd Etiology, diagnosis and therapeutic management of granuloma annulare: an update. Am. J. Clin. Dermatol. 2013, 14, 279-290 Histopathology: 5. Farrar CW, Bell HK, Dobson CM, Sharpe GR. Perforating granuloma annulare Two punch biopsies showed a patchy lymphocytic infiltrate in the dermis, presenting on the ears. Br. J. Dermatol. 2002, 147, 1026-1028 accompanied by histiocytes and some histiocytic giant cells palisaded around 6.Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually less cellular areas. The latter have thick collagen bundles with diminished transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun Figure 3. Right Palmar Hand, 4X: Higher power view of the Figure 6. Right Antecubital Fossa, 20X: Palisaded 5;64(RR-03):1-137 numbers of fibroblasts in their centers. There is irreg ular• epidermal hyperplasia intraepidermal channel and surrounding granulomatous granulomatous inflammation consisting of histiocytes inflammation. surrounding central areas of collagen with slight mucin 7. Brodell, RT,Stratman E, Ofori, AO. Granuloma annulare. 2017 July 17 with small collections of neutrophils within some of the more jagged foci, and deposition. granulation tissue near them.