Granuloma Annulare 

  • Author: Ruby Ghadially, MBChB, FRCP(C)Derm; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 25, 2012
 

Background

Granuloma annulare (GA) is a benign inflammatory dermatosis. T. Colcott Fox first described granuloma annulare in 1895; however, not until 1902 did Radcliffe-Crocker label it as granuloma annulare.

Granuloma annulare is relatively common disease that occurs in all age groups, but it is rare in infancy. Granuloma annulare is characterized clinically by dermal papules and annular plaques. The precise cause of granuloma annulare is unknown. Histological examination reveals foci of degenerative collagen associated with palisaded granulomatous inflammation.

The following clinical variants are recognized:

  • Localized granuloma annulare: This is the most common form. Localized granuloma annulare is characterized by skin-colored to violaceous lesions up to 5 cm in diameter. Usually, the epidermis has attenuated surface markings. Annular rings with solitary firm papules or nodules may be present. Localized granuloma annulare has a predilection for the feet, ankles, lower limbs, and wrists.
  • Generalized granuloma annulare: This form occurs predominantly in adults. The trunk is usually involved, as well as the neck, extremities, face, scalp, palms, and soles. Lesions range from widespread papules to annular plaques to large, discolored patches with a variety of coloration from yellow to violaceous.
  • Subcutaneous granuloma annulare[1, 2] : This form occurs predominantly in children. Subcutaneous granuloma annulare is characterized by firm or hard asymptomatic nodules in the deep dermis or subcutaneous tissues, with individual lesions measuring from 5 mm to 4 cm in diameter. They are prevalent on the anterotibial plateau, ankles, dorsal feet, buttocks, hands, scalp, and eyelids.
  • Perforating granuloma annulare[3] : This form is very rare. Perforating granuloma annulare is usually localized to the dorsal hands and fingers or may be generalized on the trunk and extremities. A variety of superficial umbilicated papules develop, with or without a discharge, that heal with scarring.
  • Arcuate dermal erythema: This is an uncommon form of granuloma annulare that manifests as infiltrated erythematous patches that may form large, hyperpigmented rings with central clearing.

Some authorities consider actinic granuloma (AG) to be a subset of granuloma annulare, but others view actinic annulare as a separate, but related, entity.[4]

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Pathophysiology

Proposed pathogenic mechanisms for granuloma annulare include cell-mediated immunity (type IV), immune complex vasculitis, and an abnormality of tissue monocytes. Some other possible mechanisms include primary degeneration of connective tissue leading to granulomatous inflammation, lymphocyte-mediated immune reaction with macrophage activation, and cytokine-mediated degradation of connective tissue.

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Epidemiology

Frequency

International

The frequency of granuloma annulare is in the general population is unknown. Granuloma annulare does not favor a particular race, ethnic group, or geographical area.

  • Localized granuloma annulare is the most common among the various subtypes.
  • Of all patients with granuloma annulare, 9-15% have the generalized variant.
  • Perforating granuloma annulare has been reported to have a prevalence of 5% among granuloma annulare subtypes; further, reports suggest that this variant may be more common in the Hawaiian Islands.

Mortality/Morbidity

Most cases of granuloma annulare resolve without adverse medical sequelae.

Sex

Women are affected by granuloma annulare twice as often as men.

Age

  • Localized granuloma annulare is most commonly found in children and in adults younger than 30 years.
  • Generalized granuloma annulare demonstrates a bimodal age distribution, occurring in patients younger than 10 years and in patients aged 30-60 years.
  • Although subcutaneous granuloma annulare can occur in adults, it is predominantly a disease of otherwise healthy children, who are typically aged 2-10 years.
  • Similarly, perforating granuloma annulare most often affects children.
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Contributor Information and Disclosures
Author

Ruby Ghadially, MBChB, FRCP(C)Derm  Professor, Department of Dermatology, University of California, San Francisco, School of Medicine

Ruby Ghadially, MBChB, FRCP(C)Derm is a member of the following medical societies: American Academy of Dermatology, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Akos Z Szabo, MD  Resident Physician, Department of Obstetrics and Gynecology, University of Heidelberg Medical Center, Germany

Disclosure: Nothing to disclose.

Amit Garg, MD  Director of Clinical Elective in Dermatology, Assistant Professor, Department of Internal Medicine, Division of Dermatology, University of Massachusetts Medical School

Amit Garg, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Student Association/Foundation

Disclosure: Abbott Immunology Honoraria Speaking and teaching; Centocor Grant/research funds Other; RegenRx Grant/research funds Other

Specialty Editor Board

James J Nordlund, MD  Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine

James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD  Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor; DLA Piper Consulting fee Consulting

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.

References

  1. Argent JD, Fairhurst JJ, Clarke NM. Subcutaneous granuloma annulare: four cases and review of the literature. Pediatr Radiol. 1994;24(7):527-9. [Medline].

  2. Felner EI, Steinberg JB, Weinberg AG. Subcutaneous granuloma annulare: a review of 47 cases. Pediatrics. Dec 1997;100(6):965-7. [Medline].

  3. Penas PF, Jones-Caballero M, Fraga J, Sanchez-Perez J, Garcia-Diez A. Perforating granuloma annulare. Int J Dermatol. May 1997;36(5):340-8. [Medline].

  4. Ghadially R. Granuloma annulare, actinic granuloma. In: Arndt K, et al, eds. Cutaneous Medicine and Surgery. WB Saunders Co; 1996:438-443.

  5. Mehta LR, Rose JW. Recurrent granuloma annulare during treatment with daclizumab. Mult Scler. Apr 2009;15(4):527-8. [Medline].

  6. Kakourou T, Psychou F, Voutetakis A, Xaidara A, Stefanaki K, Dacou-Voutetakis C. Low serum insulin values in children with multiple lesions of granuloma annulare: a prospective study. J Eur Acad Dermatol Venereol. Jan 2005;19(1):30-4. [Medline].

  7. Li A, Hogan DJ, Sanusi ID, Smoller BR. Granuloma annulare and malignant neoplasms. Am J Dermatopathol. Apr 2003;25(2):113-6. [Medline].

  8. O'Brien JP, Regan W. Actinically degenerate elastic tissue is the likely antigenic basis of actinic granuloma of the skin and of temporal arteritis. J Am Acad Dermatol. Feb 1999;40(2 Pt 1):214-22. [Medline].

  9. De Maeseneer M, Vande Walle H, Lenchik L, Machiels F, Desprechins B. Subcutaneous granuloma annulare: MR imaging findings. Skeletal Radiol. Apr 1998;27(4):215-7. [Medline].

  10. Shehan JM, El-Azhary RA. Magnetic resonance imaging features of subcutaneous granuloma annulare. Pediatr Dermatol. Jul-Aug 2005;22(4):377-8. [Medline].

  11. Blume-Peytavi U, Zouboulis CC, Jacobi H, Scholz A, Bisson S, Orfanos CE. Successful outcome of cryosurgery in patients with granuloma annulare. Br J Dermatol. Apr 1994;130(4):494-7. [Medline].

  12. Harth W, Linse R. Topical tacrolimus in granuloma annulare and necrobiosis lipoidica. Br J Dermatol. Apr 2004;150(4):792-4. [Medline].

  13. Jain S, Stephens CJ. Successful treatment of disseminated granuloma annulare with topical tacrolimus. Br J Dermatol. May 2004;150(5):1042-3. [Medline].

  14. Rigopoulos D, Prantsidis A, Christofidou E, Ioannides D, Gregoriou S, Katsambas A. Pimecrolimus 1% cream in the treatment of disseminated granuloma annulare. Br J Dermatol. Jun 2005;152(6):1364-5. [Medline].

  15. Kuwahara RT, Naylor MF, Skinner RB. Treatment of granuloma annulare with topical 5% imiquimod cream. Pediatr Dermatol. Jan-Feb 2003;20(1):90. [Medline].

  16. Badavanis G, Monastirli A, Pasmatzi E, Tsambaos D. Successful treatment of granuloma annulare with imiquimod cream 5%: a report of four cases. Acta Derm Venereol. 2005;85(6):547-8. [Medline].

  17. Kerker BJ, Huang CP, Morison WL. Photochemotherapy of generalized granuloma annulare. Arch Dermatol. Mar 1990;126(3):359-61. [Medline].

  18. Looney M, Smith KM. Isotretinoin in the treatment of granuloma annulare. Ann Pharmacother. Mar 2004;38(3):494-7. [Medline].

  19. Passeron T, Fusade T, Vabres P, Bousquet-Rouaud R, Collet-Vilette AM, Dahan S, 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. Dec 21 2011;[Medline].

  20. Piaserico S, Zattra E, Linder D, Peserico A. Generalized granuloma annulare treated with methylaminolevulinate photodynamic therapy. Dermatology. 2009;218(3):282-4. [Medline].

  21. Weisenseel P, Kuznetsov AV, Molin S, Ruzicka T, Berking C, Prinz JC. Photodynamic therapy for granuloma annulare: more than a shot in the dark. Dermatology. 2008;217(4):329-32. [Medline].

  22. Marcus DV, Mahmoud BH, Hamzavi IH. Granuloma annulare treated with rifampin, ofloxacin, and minocycline combination therapy. Arch Dermatol. Jul 2009;145(7):787-9. [Medline].

  23. Weber HO, Borelli C, Rocken M, Schaller M. Treatment of disseminated granuloma annulare with low-dose fumaric acid. Acta Derm Venereol. 2009;89(3):295-8. [Medline].

  24. Rosmarin D, LaRaia A, Schlauder S, Gottlieb AB. Successful treatment of disseminated granuloma annulare with adalimumab. J Drugs Dermatol. Feb 2009;8(2):169-71. [Medline].

  25. Torres T, Pinto Almeida T, Alves R, Sanches M, Selores M. Treatment of recalcitrant generalized granuloma annulare with adalimumab. J Drugs Dermatol. Dec 2011;10(12):1466-8. [Medline].

  26. [Guideline] Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg. Sep-Oct 2006;45(5 Suppl):S1-66. [Medline].

  27. Gass JK, Todd PM, Rytina E. Generalized granuloma annulare in a photosensitive distribution resolving with scarring and milia formation. Clin Exp Dermatol. Jul 2009;34(5):e53-5. [Medline].

 
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