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Granuloma Annulare

Granuloma annulare is an inflammatory dermatosis, a common skin ailment with characteristic smooth, discolored, raised patches or rashes on the skin, usually thickened at the border forming circular or annular ring. This skin condition is also called necrobiotic papulosis. It is usually found on hands and feet, commonly over knuckles and joints. The annular rings are pinkish and erythematous, thin papules on its extremities. Granuloma annulare can affect children, young adults, teenagers and rarely found in elderly people.Granuloma annulare is a non-contagious disease.


What are the causes of Granuloma annulare?

There is no exact reasoning for this type of dermatitis to occur, but in some cases the condition can be triggered by the following:

  • Infection such as Hepatitis
  • Animal or insect bites
  • Sun exposure
  • Vaccinations
  • Tuberculin skin test
  • Other minor injuries leading to skin aberration.

What are the different types of Granuloma Annulare?

Granuloma annulare has a tendency to occur at any site on the body and the rashes are widespread in nature. It remains only on the surface of the skin, showing zero penetration. There are no other prominent symptoms except that the rash area becomes tender and the plaque may change in size, shape and position. Many times small rings join together to form a common big papule as they spread on the skin.

Localized Granuloma Annulare

  • It is the most common variant among children
  • One or more bumps, skin-colored and round, appear on the knuckles and joints.
  • The center shows a depression.
  • It can also affect the upper skin of the ankle and foot and also on skin over the elbows.

Generalized Granuloma Annulare

  • Usually seen in adults are these extensive looking, skin-colored or dark pink patches.
  • On joining to become widespread, these patches are small papules or rings more than 10cm in diameter, arranged in a symmetrical manner.
  • They are mainly observed in the skin folds like the groin or the armpits.

Subcutaneous Granuloma Annulare

  • These rubbery lumps, which appear to be beneath the skin, are commonly found in children.
  • Scalp, shins and fingertips are where these papules frequently occur.
  • It can be also termed as pseudo-rheumatoid nodules.

Perforating Granuloma Annulare

  • In this variant, damaged collagen found in the body is eliminated from the epidermal layer of the skin in the form of plaques.
  • Usually observed on hands, these plaques may be found anywhere on the body.
  • These plaques have a tendency to leave scars.
  • These lesions are generally tender and itchy.

Atypical Granuloma Annulare

  • In this case, papules are found in uncommon places such as ears, palms and face.
  • It may also include Granuloma spreading due to sun exposure.
  • A symptomatic and severe flaring up of Granuloma also comes under this condition.

Intestinal Granulomatous Dermatitis

  • It is a clinical condition seen in  patients with severe granuloma annulare.

Pathophysiology

Researchers have proposed various pathogenic mechanisms for Granuloma annulare to occur which include immune complex vasculitis, cell-mediated immunity type IV and abnormal proliferation of tissue monocytes.

Other mechanisms may include lymphocyte-mediated immune reaction, macrophage activation, cytokine-mediated connective tissue degradation.

Diagnosis of Granuloma Annulare

Granuloma annulare is unpredictable as it can flare up and diminish all by itself and then return again after some time. In general cases, the disease clears all by itself, whether treatment is provided or not.

At times when the diagnosis cannot be judged based on obvious symptoms, biopsy is carried out to show necrobiotic degeneration of collagen present in the epidermis which is not a true granuloma.

Granuloma Annulare Treatment

In all common cases, no treatment is required as the onset subsides on its own within a few months without any scars. But, in rare cases, they may persist for more than a decade. The following methods of treating the symptoms of Granuloma annulare are known, but their success is undetermined.

Local Therapy

  • Topical application of corticosteroid ointment or cortisone cream.
  • Cortisone can be injected underneath the skin.
  • Destruction of the lesions by cryotherapy (using liquid nitrogen) or by laser ablation.
  • Using imiquimod cream.
  • Topical application of calcineurin inhbtors like pimecrolimus and tacrolimus.

Systemic Therapy

The systemic treatment may be used to gain control over widespread case of Grauloma annulare. The treatments given below might be capable of successful dissemination of the disease but, cannot be relied upon completely.

  • Use of systemic steroids
  • Methotrexate
  • Isotretinoin
  • Hydroxychloroquine
  • Potassium iodide
  • Dapsone
  • Photochemotherapy
  • Cyclosporin
  • Combinational antibiotic therapy

Granuloma Annulare FAQs

How long does it take to get rid of Granuloma annulare?

A localized granuloma clears by itself in a time span of a few months, but it may be recurrent. A generalized or atypical variant may persist for a very long period of time.

Is a blood test recommended for diagnosis of Granuloma annulare?

For apt diagnosis, the general practitioner may recommend blood glucose level to be checked as in some cases granuloma is found to be linked to diabetes.

Can Granuloma annulare be called  an autoimmune disease?

While Granuloma annulare is thought to be associated with diabetes and thyroid disorders, it can also be linked to autoimmune diseases like rheumatoid arthritis, Lyme disease, Addison’s disease etc.

Granuloma Annulare Pictures

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