eMedicine Specialties > Emergency Medicine > Dermatology

Granuloma, Annulare and Pyogenic: Differential Diagnoses & Workup

Author: Richard Lichenstein, MD, Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Sep 18, 2008

Differential Diagnoses

Bites, Insects
Catscratch Disease
Erythema Multiforme
Syphilis
Tick-Borne Diseases, Lyme
Tinea

Other Problems to Be Considered

Amelanotic melanoma (PG)
Amyloidosis
Annular elastolytic granuloma
Annular lichen planus
Bacillary angiomatosis (PG)
Creeping eruption
Erythema annulare centrifugum
Erythema chronicum migrans
Erythema elevatum diutinum
Fibrosarcoma (PG)
Granuloma multiforme
Kaposi sarcoma
Lipoid proteinosis
Majocchi granuloma
Metastatic lesions (PG)
Necrobiosis lipoidica
Peripheral giant cell granuloma (PG)
Peripheral ossifying fibroma (PG)
Ringworm
Rheumatoid nodules
Squamous cell carcinoma (PG)
Subacute lupus erythematosus
Tuberculous granulomas
Verrucous carcinoma (PG)
Verruca plana
Xanthomas

Workup

Laboratory Studies

  • Laboratory studies may be helpful if the diagnosis of granuloma annulare cannot be ruled out with a complete history emphasizing issues such as diet, weight loss, and/or fever. If an accurate history is unobtainable, a CBC and erythrocyte sedimentation rate (ESR) should be obtained.
  • No laboratory studies are needed to make the diagnosis of pyogenic granuloma. CBC, human chorionic gonadotropin (HCG), HIV, and biochemical profiles are needed only if there is concern for other etiologies.
  • Check blood glucose level if there is concern of diabetes mellitus and granuloma annulare.
  • Check rheumatoid factor if symptoms of rheumatoid arthritis are present.

Imaging Studies

  • Granuloma annulare
    • Radiographs are not necessary for diagnosis of granuloma annulare but may be helpful if other problems are suspected.
    • In granuloma annulare, the lesion is soft tissue mass without any calcification or bony involvement.
  • Pyogenic granuloma: Imaging studies are not useful in pyogenic granuloma.

Procedures

  • Skin biopsy
    • To obtain a specimen, a 22- or 24-gauge needle may be gently passed tangentially just below the superficial capsular layer of the lesion, then flushed with saline to yield a small but adequate specimen.
    • Skin biopsy is diagnostic for granuloma annulare. Because the lesions regress, biopsy is needed only when a definitive diagnosis is required.
    • Skin biopsy is also diagnostic for pyogenic granuloma.

More on Granuloma, Annulare and Pyogenic

Overview: Granuloma, Annulare and Pyogenic
Differential Diagnoses & Workup: Granuloma, Annulare and Pyogenic
Treatment & Medication: Granuloma, Annulare and Pyogenic
Follow-up: Granuloma, Annulare and Pyogenic
References
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References

  1. Ziemer M, Grabner T, Eisendle K, Baltaci M, Zelger B. Granuloma annulare - a manifestation of infection with Borrelia?. J Cutan Pathol. Jun 18 2008;[Medline].

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

  3. Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. Jan-Feb 2004;21(1):10-3. [Medline].

  4. Arroyo MP. Generalized granuloma annulare. Dermatol Online J. Oct 2003;9(4):13. [Medline].

  5. Dillman AM, Miller RC, Hansen RC. Multiple pyogenic granulomata in childhood. Pediatr Dermatol. Mar 1991;8(1):28-31. [Medline].

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

  7. Grimalt R, Caputo R. Symmetric pyogenic granuloma. J Am Acad Dermatol. Oct 1993;29(4):652. [Medline].

  8. Medlock MD, McComb JG, Raffel C, Gonzalez-Gomez I. Subcutaneous palisading granuloma of the scalp in childhood. Pediatr Neurosurg. 1994;21(2):113-6. [Medline].

  9. Mooney MA, Janniger CK. Pyogenic granuloma. Cutis. Mar 1995;55(3):133-6. [Medline].

  10. Pomeranz AJ, Fairley JA. The systematic evaluation of the skin in children. Pediatr Clin North Am. Feb 1998;45(1):49-63. [Medline].

  11. Scheinfeld NS. Pyogenic granuloma. Skinmed. Jan-Feb 2008;7(1):37-9. [Medline].

  12. Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. Jul 1996;41(7):467-70. [Medline].

  13. Tan HH, Goh CL. Granuloma annulare: a review of 41 cases at the National Skin Centre. Ann Acad Med Singapore. Nov 2000;29(6):714-8. [Medline].

  14. Tay YK, Weston WL, Morelli JG. Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser. Pediatrics. Mar 1997;99(3):368-70. [Medline].

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Further Reading

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Keywords

granuloma annulare, pyogenic granuloma, skin nodule, GA, dermatosis, PG, vascular tumor of skin and mucous membrane, papule, nodule, peduncle, subcutaneous GA, self-limited dermatosis, disorder of angiogenesis, sclerosis, lymphedema, joint ankylosis, necrobiosis lipoidica diabeticorum, rheumatoid nodules, benign vascular tumor

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Contributor Information and Disclosures

Author

Richard Lichenstein, MD, Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine
Richard Lichenstein, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Edward A Michelson, MD, Program Director, Associate Professor, Department of Emergency Medicine, University Hospital Health Systems in Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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