Core Dermatology Diagnoses / CategoriesInflammatory

Granuloma Annulare

Author: Faculty Reviewer:

Publish date: Posted on
Last updated: May 25, 2022

Keywords #

granuloma annulare
necrobiotic papulosis
GA

Diagnosis #

Granuloma annulare (GA) is a benign skin condition that is often asymptomatic and is self-limited. Localized GA is by far the most common form of GA, and is characterized by  pink or violet-pink, non-scaly, annular papules or plaques with central clearing and an intermediately firm border. While it is self-limited, the course may be prolonged, often persisting for two or more years [1].

Key Concepts #
  • GA is benign and often asymptomatic.
  • It is self-limited, but lesions can persist for two or more years.
  • Localized GA presents with pink or violet-pink, non-scaly, annular papules/plaque(s) with central clearing [1].
  • GA is associated with diabetes mellitus and dyslipidemia; screening tests may be warranted [2,3].
  • Patients who desire therapy utilize high potency topical or intralesional corticosteroids [4,5].
Epidemiology #

While the incidence and prevalence of GA have not been studied, estimates indicate that 0.1-0.4% of new dermatologic patients have GA [1]. Localized GA most commonly arises prior to age thirty [6,7]. Females are at increased risk for GA, with localized GA ratio of 2.5:1 for females to males [1,8].

Clinical Features #
  • Localized GA appears as a non-scaly, pink or violet-pink, annular plaque with a moderately firm border and central clearing, about 50% of patients will have more than one lesion [1].
  • Localized GA is commonly found on a distal extremity, most commonly the wrists, ankles, dorsal hands, and dorsal feet [1].
  • Localized GA grows slowly in a centrifugal pattern, not usually exceeding 5 cm in diameter [1].
Differential Diagnoses #
Diagnostic Workup #

Granuloma annulare is often diagnosed clinically based upon the presence of an asymptomatic, non-scaly, pink or violet-pink, annular plaque with peripheral papules on a distal extremity. No diagnostic workup is required to diagnose granuloma annulare.

Biopsy can be helpful in atypical presentations. It reveals lymphohistiocytic infiltrate with degeneration of collagen and mucin deposition in one of two distinct patterns, interstitial or palisaded [8].

KOH preparation is utilized to rule out tinea corporis if there is clinical suspicion.

Treatment #

Treatment is not required for granuloma annulare, as localized GA is self-limited. However, as individual lesions may persist for more than two years, some patients desire pharmacologic therapy. High potency topical and intralesional corticosteroids are often utilized as first-line therapy, as they have the highest efficacy. Cryotherapy, UV-based therapy, and other topical agents such as calcineurin inhibitors have been used with lower efficacy, especially in patients whose lesions are refractory to corticosteroids [9,10,11].

References #
  1. Muhlbauer, JE. Granuloma annulare. Journal of the American Academy of Dermatology. 1980; 3:217.
  2. Muhlemann MF. Williams DR. Localized granuloma annulare is associated with insulin-dependent diabetes mellitus. British Journal of Dermatology. 1984; 111:325.
  3. Wu W, Robinson-Bostom L, Kokkotou E, et al. Dyslipidemia in granuloma annulare: a case-control study. Archives of Dermatology. 2007; 1143:946.
  4. Volden G. Successful treatment of chronic skin diseases with clobetasol propionate and a hydrocolloid occlusive dressing. Acta Dermato-Venereologica. 1992; 72:69.
  5. Rallis E, Stavropoulou E, Korfitis C. Granuloma annulare of childhood successfully treated with potent topical corticosteroids previously unresponsive to tacrolimus ointment 0.1%: report of 3 cases. Clinical and Experimental Dermatology. 2009; 34:e475.
  6. Rapelanoro-Rabenja F, Maleville J, Taieb A. Localized granuloma annulare in children: outcome in 30 cases. Archives de Pediatrie. 1995; 2:1145.
  7. Mutasim DF, Bridges AG. Patch granuloma annulare: clinicopathologic study of 6 patients. Journal of the American Academy of Dermatology. 2000; 42:217.
  8. Gunes P, Goktay F, Mansur AT, et al. Collagen-elastic tissue changes and vascular involvement in granuloma annulare: a review of 35 cases. Journal of Cutaneous Pathology. 2009; 36:838.
  9. Blume-Peytavi U, Zouboulis CC, Jacobi H, et al. Successful outcome of cryosurgery in patients with granuloma annulare. British Journal of Dermatology. 1994; 130:494.
  10. Grundmann-Kollmann M, Ochsendorf FR, Zollner TM, et al. Cream psoralen plus ultraviolet A therapy for granuloma annulare. British Journal of Dermatology. 2001; 144:996.
  11. Grieco T, Cantisani C, Faina P, et al. Tacrolimus 0.1% and granuloma annulare: description of three cases. Journal of the European Academy of Dermatology and Venereology. 2009; 23:1445.
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