Localized Granuloma Annulare

Localized Granuloma Annulare is the most common form of the disease and is primarily observed in children (90% of cases) and young individuals. It is characterized by the appearance of small (0.1-0.5 cm in diameter), firm, smooth, hemispherical papules of pink, red, livid, or normal skin color. These papules are typically arranged in a circle or in groups forming a semi-annular pattern and are commonly found on the backs of the hands, feet, shins and forearms (60% on hands and arms, 20% on feet and shins). Less commonly, it affects the neck, trunk, wrists, ankles, periorbital area, eyelids, scalp, and occasionally the palms and soles. Cases of genital localization have been reported.

The peripheral zone of annular eruptions consists of multiple discrete or confluent papules, macules, or nodules with a smooth surface that is reddish, livid, or flesh-colored. The peripheral zone has a moderately firm consistency to palpation. The skin within the annular eruptions may have a purplish or pigmented appearance. Isolated firm papules and nodules may be present in addition to the annular elements.

In the papular variant, the configuration of the eruptions is not circular and the papules often have a central dimple, especially on the hands, and are isolated from each other.

There are no subjective sensations. The lesions gradually increase in diameter from 1 to 5 cm or more. Over time, they may partially resolve or recur at the same site. The localized form may be associated with the subcutaneous and patch-like variants of granuloma annulare.

Deep Granuloma Annulare

Deep Granuloma Annulare is characterized by the subcutaneous location of the nodules. It is most commonly observed in children under six years of age and presents as painless, firm, solitary or multiple deep dermal or subcutaneous nodules on the shins, forearms, elbows, backs of the hands, fingers, and scalp. The periorbital area (usually the upper eyelid) and genital area may also be affected. Individual nodules may range in size from 6 mm to 3.5 cm in diameter. Nodules on the extremities are usually mobile, but may become immobile due to connections with fasciae on the scalp and in the orbital region. Recurrence may be observed after surgical treatment.

Disseminated Granuloma Annulare

Disseminated Granuloma Annulare is characterized by multiple foci of eruptions on different parts of the body. This form occurs in approximately 8-15% of cases of granuloma annulare, more commonly in adults and rarely in children. Most affected individuals are over 50 years of age. Groups of papules, nodules, and patches of flesh-colored, pink, purple, brownish, or yellowish hues are observed throughout the body. However, unlike the localized form, the distal parts of the limbs, trunk, and neck are more commonly affected. The face, scalp, palms, and soles may also be involved. The eruptions are multiple, scattered, or confluent, which may give the lesions a reticular appearance, but without a significant tendency toward circular arrangement. Polymorphism of eruptions is noted and symmetry is a typical feature. This form of the disease follows a chronic relapsing course, rarely resolves spontaneously, and is more resistant to therapy than the localized form.

Perforating Granuloma Annulare

Perforating Granuloma Annulare accounts for approximately 5% of all cases of the disease. Half of those affected are children or adolescents. It is considered a manifestation of transepidermal elimination of necrobiosis within collagen, but it may also be a traumatic variant of localized granuloma annulare. It is usually observed on the dorsum of the hands or fingers. The eruptions present as papules that coalesce into large plaques with a central plug. When pressed, a gelatinous substance is expelled from the plug; subsequently, crusts form and the lesions have a central dimple. Patients often complain of itching or pain during eruptions. The affected areas heal over several months or years with the formation of atrophic and hyperpigmented scars.

Patch granuloma annulare

Patch granuloma annulare is more common in adult females. It manifests as erythematous reddish-brown or purple patches without a ring-like configuration, with irregular borders. Generalized confluent erythematous forms have been described in HIV-infected individuals.

The diagnosis of granuloma annulare is primarily based on clinical presentation; however, in certain cases (suspected disseminated and deep forms of the disease), histopathologic examination of skin biopsies is necessary.

• Erythema elevatum diutinum
• Tuberculoid type of leprosy
• Papular form of sarcoidosis
• Necrobiosis lipoidica
• Rheumatic nodules
• Lichen planus
• Psoriasis
• Tinea corporis

Treatment Objectives

• Resolution of eruptions
• Prevention of recurrences

General Notes:

• When planning therapy, it's important to consider the tendency of granuloma annulare to spontaneously resolve. In approximately 75% of cases, lesions spontaneously resolve within 2 years. Although the recurrence rate reaches 40%, new lesions may also disappear spontaneously. If necessary, correction of carbohydrate metabolism is performed, along with treatment of any concomitant pathology (tuberculosis, diabetes).
• For localized granuloma annulare, topical glucocorticosteroids are the preferred treatment. For disseminated skin involvement, systemic medications or phototherapy are used in combination with topical therapy.

Topical Therapy

Glucocorticosteroids:

• Hydrocortisone 17-butyrate, cream, ointment 0.1%, once daily in the evening for 14 days, then once every 2 days for 2-3 weeks.
• Alclometasone dipropionate, cream, ointment 0.05%, once daily in the evening for 14 days, then once every 2 days for 2-3 weeks.
• Betamethasone dipropionate, cream, ointment 0.025%, 0.05%, once daily in the evening for 14 days, then once every 2 days for 2-3 weeks.
• Betamethasone valerate, cream, ointment 0.1%, once daily in the evening for 14 days, then once every 2 days for 2-3 weeks.
• Methylprednisolone aceponate, cream, ointment, emulsion 0.1%, once daily in the evening for 14 days, then once every 2 days for 2-3 weeks.
• Mometasone furoate, cream, ointment, lotion 0.1%, once daily in the evening for 14 days, then once every 2 days for 2-3 weeks.
• Clobetasol propionate, cream, ointment 0.05%, once daily in the evening for 14 days, then once every 2 days for 2-3 weeks.

Systemic Therapy

• Tocopheryl acetate: for children aged 3-10 years, 50-100 mg orally per day; for children older than 10 years, 100-200 mg orally per day; for adults, 200-400 mg orally per day for 20-40 days. (*Need more investigations)
• Vitamin E + retinol: 1 tab 1-3 times daily orally for 1 month. (*Need more investigations)
• Vitamin C + rutin: for children under 5 years, 1-2 tablets daily orally; for children aged 5-10 years, 1 tablet twice daily orally; for children older than 10 years and adults, 1 tablet 3 times daily orally for 20-40 days. (*Need more investigations)

Destructive Therapy

• Cryotherapy: once every 7-10 days, 3-5 procedures per lesion. The entire surface of small lesions and the active edges of larger lesions (diameter over 4 cm) are treated. Temporary side effects (pain, blister formation, local edema) and long-term complications (localized hypopigmentation and peripheral hyperpigmentation) are possible.

Treatment for Pregnant Patients:

• Topical application of tocopheryl acetate (vitamin E) twice daily, with one application under occlusion, for 2 weeks. (Need more investigations)
• Cryotherapy: once every 7-10 days, 3-5 procedures per lesion.