Granuloma Annulare

  • Author: Ruby Ghadially, MBChB, FRCP(C)Derm; Chief Editor: William D James, MD  more...
Updated: May 24, 2016


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 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] : 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[2] : 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.[3]



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.



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.


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


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.



Spontaneous resolution of localized granuloma annulare has occurred within 2 years in 50% of cases, although lesions may last weeks to decades. Recurrence, often at the same site, is noted in 40% of cases.

Generalized granuloma annulare has a more chronic course, with rare spontaneous resolution, poor response to treatment, and frequent relapses.

Subcutaneous granuloma annulare lesions often spontaneously regress. Local or distant recurrences have been reported in 20-75% of cases in different studies.


Patient Education

Patients and families should be reassured about the typically benign nature and course of granuloma annulare.

Contributor Information and Disclosures

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, Society for Investigative Dermatology

Disclosure: Nothing to disclose.


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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

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

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