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Granuloma Annulare
Aka: Granuloma Annulare
- See Also
- Skin Conditions in Diabetes Mellitus
- Acanthosis Nigricans
- Necrobiosis Lipoidica diabeticorum
- Diabetic Dermopathy
- Diabetic Ulcer
- Diabetes Mellitus
- Type I Diabetes Mellitus
- Type II Diabetes Mellitus
- Insulin Resistance Syndrome
- Glucose Metabolism
- Diabetes Mellitus Education
- Diabetes Mellitus Complications
- Diabetic Ketoacidosis
- Hyperosmolar Hyperglycemic State
- Diabetes Mellitus Control in Hospital
- Diabetes Mellitus Glucose Management
- Hypertension in Diabetes Mellitus
- Hyperlipidemia in Diabetes Mellitus
- Diabetic Retinopathy
- Diabetic Nephropathy
- Diabetic Neuropathy
- Definition
- Benign, self-limited annular rash in age <30 years
- Epidemiology
- Occurs most commonly in young women
- Most patients are under age 30 years
- Associated Conditions
- Most cases occur without underlying condition
- Diabetes Mellitus (up to 12% of cases)
- Post-Skin Trauma (e.g. Insect Bites)
- Following Tuberculin Skin Tests
- Malignancy: Lymphoma (usually), Prostate Cancer
- Viral Infections
- Epstein Barr Virus
- Herpes Zoster
- HIV Infection
- Symptoms
- Asymptomatic or mild Pruritus
- Signs
- Characteristics
- Initial
- Flesh-colored Papule
- Papule involutes centrally
- Forms Annular Lesion (ring shape)
- Later
- Ring of Papules enlarges up to 5 cm diameter
- Distribution
- Dorsolateral feet and ankles (most common)
- Dorsolateral hands and wrists
- Less commonly may occur anywhere
- Other distinguishing features
- Palms, Scalp and Plantar surfaces spared
- No scale
- No associated Vesicles or Papules
- Types
- Localized Granuloma Annulare (75% of cases)
- Typical distribution as above
- Spontaneous resolution by 2 years in 50% of cases
- Disseminated Granuloma Annulare
- Ten or more lesions with widespread involvement
- Increased association with Diabetes Mellitus
- Lesions may persist for >4 years
- Generalized perforating Granuloma Annulare (rare)
- Small umbilicated 1-4 mm Papules
- Seen in children and young adults
- Distribution
- Localized form: arms, Pelvis
- Generalized form: Trunk, Abdomen, arms, legs
- Subcutaneous Granuloma Annulare
- Large, deep Skin-Colored Nodules
- Young children (Age 2-5 years)
- Distribution
- Hands and fingers
- Scalp
- Buttocks
- Elbows and knees
- Perioral
- May occur in clusters
- No associated underlying conditions
- Actinic Granuloma Annulare
- Sun-exposed skin involvement
- Differential Diagnosis
- See Annular Lesions
- Distinguishing features of Granuloma Annulare
- Smooth skin surface
- No overlying scale
- No associated Vesicles or Pustules
- Similar appearing lesions
- Tinea Manus or Tinea Corporis
- Scale, Papules or Vesicles present
- Erythema Migrans (Lyme Disease)
- Tertiary Syphilis
- Nummular Eczema
- Psoriasis
- Erythema annulare centrifigum
- Discoid Lupus
- Sarcoidosis
- Labs
- Fasting Glucose
- Glucose Intolerance common
- Biopsy
- May appear similar to Necrobiosis Lipoidica
- Characteristic findings
- Epithelioid histiocytes surround anuclear Dermis
- Mucin deposition
- May be reported as focal collagen degeneration
- With reactive inflammation and fibrosis
- Management
- Most lesions do not require treatment
- All treatments risk scarring
- Corticosteroids
- Intralesional Corticosteroid
- Kenalog 2.5 to 5 mg/ml injected into raised border
- Topical Corticosteroids under Occlusion
- Cryotherapy
- Treatments for refractory cases (by Dermatologists)
- All based on case reports of <10 patients per study
- Toxicity limits use in primary care
- Include: Dapsone, Accutane, Fumaric acid esters
- Course
- Resolution without treatment within months to 2 years
- Recurrence occurs in 40% of children
- Types associated with slower and incomplete resolution
- Disseminated Granuloma Annulare
- References
- Habif (1996) Clinical Dermatology, Mosby, p. 786
- Cyr (2006) Am Fam Physician 74:1729-34 [PubMed]
- Hsu (2001) Am Fam Physician 64(22): 289-96 [PubMed]
- Smith (1997) Int J Dermatol 36:326-33 [PubMed]