II. Definition

  1. Benign, self-limited annular rash in age <30 years

III. Epidemiology

  1. Occurs most commonly in young women
  2. Most patients are under age 30 years

IV. Associated Conditions

  1. Most cases occur without underlying condition
  2. Diabetes Mellitus (up to 12% of cases)
  3. Post-Skin Trauma (e.g. Insect Bites)
  4. Following Tuberculin Skin Tests
  5. Malignancy: Lymphoma (usually), Prostate Cancer
  6. Viral Infections
    1. Epstein Barr Virus
    2. Herpes Zoster
    3. HIV Infection

V. Symptoms

  1. Asymptomatic or mild Pruritus

VI. Signs

  1. Characteristics
    1. Initial
      1. Flesh-colored Papule
      2. Papule involutes centrally
      3. Forms Annular Lesion (ring shape)
    2. Later
      1. Ring of Papules enlarges up to 5 cm diameter
  2. Distribution
    1. Dorsolateral feet and ankles (most common)
    2. Dorsolateral hands and wrists
    3. Less commonly may occur anywhere
  3. Other distinguishing features
    1. Palms, Scalp and Plantar surfaces spared
    2. No scale
    3. No associated Vesicles or Papules

VII. Types

  1. Localized Granuloma Annulare (75% of cases)
    1. Typical distribution as above
    2. Spontaneous resolution by 2 years in 50% of cases
  2. Disseminated Granuloma Annulare
    1. Ten or more lesions with widespread involvement
    2. Increased association with Diabetes Mellitus
    3. Lesions may persist for >4 years
  3. Generalized perforating Granuloma Annulare (rare)
    1. Small umbilicated 1-4 mm Papules
    2. Seen in children and young adults
    3. Distribution
      1. Localized form: arms, Pelvis
      2. Generalized form: Trunk, Abdomen, arms, legs
  4. Subcutaneous Granuloma Annulare
    1. Large, deep Skin-Colored Nodules
    2. Young children (Age 2-5 years)
    3. Distribution
      1. Hands and fingers
      2. Scalp
      3. Buttocks
      4. Elbows and knees
      5. Perioral
    4. May occur in clusters
    5. No associated underlying conditions
  5. Actinic Granuloma Annulare
    1. Sun-exposed skin involvement

VIII. Differential Diagnosis

  1. See Annular Lesions
  2. Distinguishing features of Granuloma Annulare
    1. Smooth skin surface
    2. No overlying scale
    3. No associated Vesicles or Pustules
  3. Similar appearing lesions
    1. Tinea Manus or Tinea Corporis
      1. Scale, Papules or Vesicles present
    2. Erythema Migrans (Lyme Disease)
    3. Tertiary Syphilis
    4. Nummular Eczema
    5. Psoriasis
    6. Erythema annulare centrifigum
    7. Discoid Lupus
    8. Sarcoidosis

IX. Labs

  1. Fasting Glucose
    1. Glucose Intolerance common
  2. Biopsy
    1. May appear similar to Necrobiosis Lipoidica
    2. Characteristic findings
      1. Epithelioid histiocytes surround anuclear Dermis
      2. Mucin deposition
      3. May be reported as focal Collagen degeneration
        1. With reactive inflammation and fibrosis

X. Management

  1. Most lesions do not require treatment
  2. All treatments risk scarring
  3. Corticosteroids
    1. Intralesional Corticosteroid
      1. Kenalog 2.5 to 5 mg/ml injected into raised border
    2. Topical Corticosteroids under Occlusion
  4. Cryotherapy
  5. Treatments for refractory cases (by Dermatologists)
    1. All based on case reports of <10 patients per study
    2. Toxicity limits use in primary care
    3. Include: Dapsone, Accutane, Fumaric acid esters

XI. Course

  1. Resolution without treatment within months to 2 years
  2. Recurrence occurs in 40% of children
  3. Types associated with slower and incomplete resolution
    1. Disseminated Granuloma Annulare

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Ontology: Granuloma Annulare (C0085074)

Definition (NCI) A localized or generalized inflammatory skin disorder characterized by the formation of papules and ring-shaped plaques in the skin. Morphologically these lesions are granulomatous inflammatory processes with central necrosis surrounded by palisading histiocytes.
Definition (MSH) Benign granulomatous disease of unknown etiology characterized by a ring of localized or disseminated papules or nodules on the skin and palisading histiocytes surrounding necrobiotic tissue resulting from altered collagen structures.
Concepts Disease or Syndrome (T047)
MSH D016460
ICD10 L92.0
SnomedCT 200953005, 267850001, 156368000, 65508009
French GRANULOME ANNULAIRE, Granulome annulaire
English GRANULOMA ANNULARE, granuloma annulare (diagnosis), granuloma annulare, Granuloma Annulare [Disease/Finding], annulare granuloma, Granulome annulare, Granuloma annulare, GA - Granuloma annulare, Granuloma annulare (disorder), granuloma; annulare, annulare; granuloma, Granuloma Annulare
Portuguese GRANULOMA ANULAR, Granuloma anular, Granuloma Anular
Spanish GRANULOMA ANULAR, granuloma anular (trastorno), granuloma anular, Granuloma anular, Granuloma Anular
Japanese 環状肉芽腫, カンジョウニクゲシュ
Swedish Granuloma annulare
Czech granulom anulární, Granuloma annulare
Finnish Rengasgranulooma
German GRANULOMA ANULARE, Granuloma anulare, Granuloma annulare
Korean 환상육아종
Polish Ziarniniak obrączkowaty
Hungarian Granuloma annulare
Norwegian Granuloma annulare
Dutch annulare; granuloom, granuloom; annulare, granuloma annulare, Granuloma annulare
Italian Granuloma anulare