History
Granuloma annulare
History should focus on issues regarding diet, weight loss, and/or fever. This will help rule out other potential diagnoses such as trauma, infection, tumor, metabolic bone or skin disease, and inflammatory or autoimmune disease. In 2018, it was reported as an adverse effect of anti–programmed cell death-1 (PD-1) immunotherapy in a series of two patients. [7]
Children with granuloma annulare are usually otherwise healthy and have the lesions for several months without any other symptoms.
Pyogenic granuloma
In patients with suspected pyogenic granuloma, history should focus on the onset and associated symptoms of the rash.
Query the patient or parents regarding a preceding history of trauma, viral or bacterial infection, pregnancy, or HIV infection.
The patient and family should be questioned regarding prior rashes, port wine stain, and prior treatment.
The presence or absence of signs such as bleeding or ulceration should be noted.
Physical Examination
Granuloma annulare
Children with granuloma annulare usually present with one or more firm, nontender soft tissue nodules on the extremities, scalp, or forehead.
Papules are 1-5 mm in diameter, flesh-colored or slightly pink, and smooth rather than scaly. They are easily distinguished from the lesions of erythema chronicum migrans, which are usually red in color and ring-shaped with central clearing.
Lesions may be generalized in children or in immunocompromised patients but are most often found along the extensor aspects of the extremities, in close proximity to joints.
Nodules of the scalp or forehead usually are fixed to periosteum and are only minimally mobile. Lesions of the extremities usually are fixed to fascia and are freely mobile.
Pyogenic granuloma
Physical examination should focus on the location and size of vascular papules, nodules, and peduncles that may be present on the skin or mucous membranes.
The presence or absence of bleeding or ulceration should be noted.
If present, other rashes should be described.
Complications
In cases of granuloma annulare without other etiology of the subcutaneous nodules, no complications are encountered.
The principal complication associated with pyogenic granuloma is hemorrhage, which can be significant and can require intervention.
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Granuloma annulare. Courtesy of Wikimedia Commons (Mierlo at English Wikipedia).
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Pyogenic granulomas are usually solitary lesions. The fingers and hands are common locations for these to develop. A history of minor trauma at the site shortly before development of the lesion is frequent.
