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Granuloma Annulare Treatment & Management

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

Medical Care

Localized granuloma annulare

Localized granuloma annulare (GA) is not often symptomatic and it has a tendency towards spontaneous resolution. Reassurance is often all that is necessary. Painful or disfiguring lesions have been treated by various methods, although the level of evidence supporting these methods is low.

Localized lesions have been treated with potent topical corticosteroids with or without occlusion for 4-6 weeks, as well as with intralesional corticosteroids with varying total doses of steroid.

Cryotherapy using liquid nitrogen or nitrous oxide as refrigerants has been shown in a prospective, uncontrolled trial to be an effective treatment for localized granuloma annulare. Secondary dyschromia may be a complication of cryotherapy.[10]

Laser therapy, using multiple different modalities including pulsed dye and excimer, has been successfully used for both localized and generalized granuloma annulare.[11, 12, 13, 14, 15]

Other anecdotes of therapeutic efficacy in both localized and generalized granuloma annulare involve tacrolimus and pimecrolimus[16, 17, 18, 19, 20, 21] and imiquimod cream.[22, 23]

Generalized granuloma annulare

Generalized granuloma annulare tends to be more persistent and unsightly. Treatment of the generalized disease is unfortunately fraught with a lack of consistently effective options. Over the last 10-15 years, success with the use of ultraviolet (UV) B, mostly narrowband UVB, a relatively harmless treatment compared with the alternatives, has made this a first-line option for generalized granuloma annulare. Multiple groups have described single or small groups of cases,[24, 25, 26, 27, 28, 29] and, in 2015, a retrospective analysis of 13 cases of generalized granuloma annulare treated with narrowband UVB was published.[30]

The available literature supports the use of phototherapy with oral psoralen and UVA (PUVA) as first-line options for generalized granuloma annulare.[31, 32, 33, 34] However, the risks of malignancy when treating an essentially benign condition must be discussed.

Finally, isotretinoin may be a first-line option based on many case reports.[35, 33, 34, 36, 37, 38, 39, 40, 41]

Piaserico et al report successful therapy for long-standing generalized granuloma annulare using methyl aminolevulinate photodynamic therapy.[42] Weisenseel et al reported moderate success with photodynamic therapy using 20% 5-aminolevulinic acid (ALA) gel.[43] Cazavara-Pinton et al reported responses in 9 of 13 patients.[44]

Marcus et al report on 6 patients with granuloma annulare that was refractory to standard treatment. The patients were treated with monthly combination therapy including rifampin at 600 mg, ofloxacin at 400 mg, and minocycline hydrochloride at 100 mg monthly for 3 months. Three to 5 months after the initiation of treatment, the plaques were cleared completely. Postinflammatory hyperpigmentation was reported by some patients. Although the treatment was successful, the authors suggested further studies may be needed to confirm this combination therapy as a successful option for recalcitrant granuloma annulare.[45] Garg and Baveja also reported successful treatment of 5 cases of generalized granuloma annulare with the same three antibiotics.[46]

Other anecdotal reports and small series describe successful systemic treatment with dapsone,[47, 48, 49, 50] steroids, pentoxifylline, antimalarials,[51, 52] cyclosporine, fumaric esters,[53] interferon-gamma, potassium iodide, nicotinamide, etanercept,[54, 55] infliximab,[56, 57, 58] and adalimumab.[59, 60, 61, 62, 63]



Gass et al report a 70-year-old man with disseminated granuloma annulare (GA) in a photosensitive distribution, who, after successful systemic and topical treatment, developed milia and scarring. This is purported to be the first report of scarring and milia formation after successful treatment of granuloma annulare.[64]

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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