34: Granuloma Annulare

Question 1

What is the most common form of granuloma annulare and its characteristics?

Answer 1

The most common form is localized granuloma annulare, characterized by annular or arcuate lesions, skin colored, erythematous, or violaceous, measuring 1 to 5 cm in diameter. The annular margin is firm to palpation and may be continuous or consist of discrete or coalescent papules. Within the annular ring, the skin may have a violaceous or pigmented appearance. Solitary firm papules or nodules may also be present, with papular lesions on the fingers appearing umbilicated.

Question 2

What are the common sites of predilection for localized granuloma annulare lesions?

Answer 2

Common sites include dorsal hands and feet, ankles, lower limbs, wrists, and less commonly eyelids, palms, and soles.

Question 3

What distinguishes generalized granuloma annulare from localized forms?

Answer 3

Generalized granuloma annulare occurs in 8% to 15% of cases, primarily in adults, and is characterized by widespread papules that may coalesce into small annular plaques or larger discolored patches. Common sites include the trunk, neck, extremities, and may affect the face, scalp, palms, and soles. Lesions may appear skin colored, pink, violaceous, tan, or yellow.

Question 4

What are the characteristics and common sites of subcutaneous granuloma annulare?

Answer 4

Subcutaneous granuloma annulare predominantly occurs in children and is characterized by firm to hard, usually asymptomatic nodules located in the deep dermis and subcutaneous tissues, measuring from 6 mm to 3.5 cm in diameter. Common sites include anterior lower legs, ankles, dorsal feet, buttocks, hands, and may also be found on the penis.

Question 5

What is the rare variant of granuloma annulare and its characteristics?

Answer 5

The rare variant is perforating granuloma annulare, characterized by transepidermal elimination of necrobiotic collagen. Common sites include localized areas on the dorsal hands and fingers and generalized over the trunk and extremities.

Question 6

What is the most likely diagnosis for a patient with annular lesions on wrists and ankles?

Answer 6

The most likely diagnosis is localized granuloma annulare. Common sites of predilection include dorsal hands and feet, ankles, lower limbs, and wrists.

Question 7

What subtype of granuloma annulare is characterized by firm, asymptomatic nodules on the anterior lower legs?

Answer 7

This is subcutaneous granuloma annulare. Other sites that might be involved include ankles, dorsal feet, buttocks, hands, and occasionally the penis.

Question 8

What subtype of granuloma annulare is characterized by widespread papules that coalesce into annular plaques?

Answer 8

This is generalized granuloma annulare, which typically has a more protracted course compared to localized granuloma annulare.

Question 9

What variant of granuloma annulare might be represented by umbilicated papular lesions on the fingers?

Answer 9

This might represent papular umbilicated granuloma annulare. Common sites of predilection for localized granuloma annulare include dorsal hands and feet, ankles, lower limbs, and wrists.

Question 10

What subtype of granuloma annulare might represent painful nodular lesions on the feet?

Answer 10

This might represent subcutaneous granuloma annulare, which is usually asymptomatic, but painful lesions are rare and may cause discomfort from footwear.

Question 11

What variant of granuloma annulare is characterized by central ulceration and discharge of creamy fluid?

Answer 11

This is perforating granuloma annulare, with its hallmark feature being transepidermal elimination of necrobiotic collagen.

Question 12

What are the common clinical features of localized granuloma annulare?

Answer 12

Localized granuloma annulare is characterized by annular or arcuate lesions that are skin colored, erythematous, or violaceous, measuring 1 to 5 cm in diameter, with firm annular margins. The skin within the annular ring may have a violaceous or pigmented appearance.

Question 13

What distinguishes generalized granuloma annulare in terms of presentation and demographics?

Answer 13

Generalized granuloma annulare occurs in 8% to 15% of cases, primarily affecting adults, and is characterized by widespread papules that may coalesce into small annular plaques or larger discolored patches.

Question 14

How does subcutaneous granuloma annulare typically present?

Answer 14

It presents as firm to hard, usually asymptomatic nodules located in the deep dermis and subcutaneous tissues, measuring from 6 mm to 3.5 cm in diameter.

Question 15

What are the characteristics and common sites of predilection for perforating granuloma annulare?

Answer 15

Perforating granuloma annulare is characterized by transepidermal elimination of necrobiotic collagen, commonly localized to the dorsal hands and fingers or generalized over the trunk and extremities.

Question 16

What are the common clinical variants of granuloma annulare?

Answer 16

Common clinical variants include papular umbilicated granuloma annulare on the hands of children and generalized follicular pustular type of granuloma annulare.

Question 17

What noncutaneous findings are associated with granuloma annulare?

Answer 17

Most patients are healthy with no other abnormal physical findings. Arthralgia is reported in association with painful lesions on the hands.

Question 18

What are some potential triggering factors for granuloma annulare?

Answer 18

Potential triggers include nonspecific mild trauma, insect/animal bite reactions, long-standing tattoos, and widespread lesions from waxing-induced pseudofolliculitis.

Question 19

How is granuloma annulare linked to systemic diseases?

Answer 19

It is primarily associated with type 1 diabetes mellitus, but also reported in type 2 DM, thyroiditis, hypothyroidism, and thyroid adenoma.

Question 20

What is the pathogenesis of granuloma annulare?

Answer 20

The pathogenesis involves a primary degenerative process of connective tissue initiating granulomatous inflammation, a lymphocyte-mediated immune reaction, and a subtle vasculitis or other microangiopathy leading to tissue injury.

Question 21

What are the potential triggers for granuloma annulare in patients with HIV?

Answer 21

Potential triggers include photosensitivity, herpes zoster scars, and generalized disease after PUVA light therapy.

Question 22

What systemic diseases are associated with granuloma annulare in relation to diabetes?

Answer 22

Systemic diseases include diabetes mellitus (primarily type 1 but also type 2) and thyroid disease, with various forms of granuloma annulare observed in diabetic patients.

Question 23

What infections or immunizations have been linked to granuloma annulare?

Answer 23

Infections linked include herpes zoster scars, chickenpox, HIV infection, Epstein-Barr virus, chronic hepatitis B and C, and vaccinations such as diphtheria toxoid and BCG immunization.

Question 24

What is the relationship between thyroid disease and granuloma annulare?

Answer 24

Granuloma annulare has been observed in patients with thyroiditis, hypothyroidism, and thyroid adenoma.

Question 25

What phenomenon might explain granuloma annulare lesions developing after waxing-induced pseudofolliculitis?

Answer 25

This might be explained by the Koebner phenomenon, where trauma induces lesions.

Question 26

What variant of granuloma annulare might represent lesions on photodamaged skin?

Answer 26

This might represent annular elastolytic giant cell granuloma, a reaction to actinic elastosis on photodamaged skin.

Question 27

What drugs have been implicated in triggering granuloma annulare?

Answer 27

Drugs include gold therapy, allopurinol, diclofenac, quinidine, intranasal calcitonin, topiramate, amlodipine, thalidomide, adalimumab, infliximab, etanercept, efalizumab, and vemurafenib.

Question 28

What systemic phenomenon might explain granuloma annulare lesions developing after a scabies infestation?

Answer 28

This might be attributed to the Koebner phenomenon, where trauma or irritation induces lesions.

Question 29

What are the clinical variants of granuloma annulare observed in children and adults?

Answer 29

In children, papular umbilicated granuloma annulare on the hands is common, while adults may present with generalized follicular pustular type of granuloma annulare.

Question 30

How does trauma contribute to the development of granuloma annulare in children?

Answer 30

Nonspecific mild trauma is a possible triggering factor, along with insect/animal bite reactions, long-standing tattoos, and widespread lesions after waxing-induced pseudofolliculitis.

Question 31

What systemic diseases are associated with granuloma annulare, particularly in relation to diabetes and thyroid conditions?

Answer 31

Diabetes Mellitus is primarily linked with type 1 DM, but cases are also reported with type 2 DM. Granuloma annulare has been observed in patients with thyroiditis, hypothyroidism, and thyroid adenoma.

Question 32

What are the potential drug-related triggers for granuloma annulare?

Answer 32

Potential triggers include gold therapy and treatments with allopurinol, diclofenac, quinidine, intranasal calcitonin, topiramate, amlodipine, thalidomide, and various biologics.

Question 33

What is intranasal calcitonin?

Answer 33

A medication used for various conditions, including osteoporosis.

Question 34

What is topiramate?

Answer 34

An anticonvulsant medication used to treat epilepsy and prevent migraines.

Question 35

What is amlodipine?

Answer 35

A calcium channel blocker used to treat high blood pressure and chest pain.

Question 36

What is thalidomide?

Answer 36

A medication used to treat certain cancers and leprosy complications.

Question 37

What are biologics?

Answer 37

Medications derived from living organisms, including adalimumab, infliximab, etanercept, efalizumab, and vemurafenib.

Question 38

What may mimic granuloma annulare?

Answer 38

Angiotensin-converting enzyme inhibitors and calcium channel blockers.

Question 39

What is the pathogenesis of granuloma annulare?

Answer 39

1. A primary degenerative process of connective tissue initiating granulomatous inflammation. 2. A lymphocyte-mediated immune reaction resulting in macrophage activation and cytokine-mediated degradation of connective tissue. 3. A subtle vasculitis or other microangiopathy leading to tissue injury.

Question 40

What types of malignancies can mimic granuloma annulare?

Answer 40

Hodgkin lymphoma, Non-Hodgkin lymphoma, Mycosis fungoides, Lennert lymphoma, B-cell disease, T-cell leukemia and lymphoma, Angioblastic T-cell lymphoma.

Question 41

What is a characteristic histopathologic finding in generalized granuloma annulare?

Answer 41

Lymphohistiocytic granuloma associated with varying degrees of connective tissue degeneration and mucin deposition.

Question 42

What are the histopathologic features of necrobiosis in granuloma annulare?

Answer 42

Single or multiple foci of inflammation with a central core of altered collagen surrounded by a wall of palisaded histiocytes.

Question 43

What laboratory tests are important in the diagnosis of granuloma annulare?

Answer 43

Skin biopsy to confirm diagnosis and positive stains for mucin and lipid to support diagnosis.

Question 44

What are the clinical implications of dyslipidemia in patients with granuloma annulare?

Answer 44

Increased prevalence of dyslipidemia has been reported in patients with granuloma annulare, particularly in cases with an annular morphology.

Question 45

What is the significance of immunofluorescence testing in granuloma annulare?

Answer 45

Immunofluorescence testing may show deposition of fibrin IgM and C3 around vessel walls or at the basement membrane zone.

Question 46

What laboratory tests might be considered for generalized granuloma annulare?

Answer 46

Lipid studies might be considered, especially in cases with an annular morphology.

Question 47

What malignancies are associated with granuloma annulare?

Answer 47

Hodgkin lymphoma, non-Hodgkin lymphoma, mycosis fungoides, and various leukemias.

Question 48

What are the characteristic histopathologic findings for generalized granuloma annulare?

Answer 48

Lymphohistiocytic granulomas associated with connective tissue degeneration and mucin deposition.

Question 49

What is the relationship between dyslipidemia and granuloma annulare?

Answer 49

There is an increased prevalence of dyslipidemia in patients with granuloma annulare, particularly in cases with an annular morphology.

Question 50

What findings might be observed in immunofluorescence testing for granuloma annulare?

Answer 50

Deposition of fibrin, IgM, and C3 around vessel walls or at the basement membrane zone.

Question 51

What histopathologic pattern is typically observed in generalized granuloma annulare?

Answer 51

An interstitial, nonpalisaded pattern of inflammation with histiocytes infiltrating among fragmented collagen bundles.

Question 52

What are the clinical implications of distinguishing between granuloma annulare and cutaneous lymphoma?

Answer 52

1. Treatment approaches differ; granuloma annulare is often self-limiting. 2. Prognosis varies; granuloma annulare generally has a better prognosis. 3. Diagnostic procedures may require different techniques. 4. Follow-up intensity differs.

Question 53

How does the histopathologic finding of necrobiosis in granuloma annulare differ from other granulomatous diseases?

Answer 53

It features a central core of altered collagen surrounded by palisaded histiocytes, which is distinct from other granulomatous diseases.

Question 54

What are the key laboratory tests for diagnosing generalized granuloma annulare?

Answer 54

1. Skin biopsy for diagnosis confirmation. 2. Stains for mucin and lipid to support diagnosis. 3. Lipid studies for dyslipidemia evaluation. 4. Immunofluorescence testing for differentiation.

Question 55

What imaging studies may be performed for subcutaneous granuloma annulare?

Answer 55

Radiographs, ultrasound, and MRI.

Question 56

What is the typical course and prognosis for localized granuloma annulare?

Answer 56

Typically resolves spontaneously without sequelae, may clear within a few weeks or persist for several years.

Question 57

What are the treatment options for granuloma annulare?

Answer 57

Treatment options include intralesional, systemic, and other therapies.

Question 58

What imaging modality might be used for lesions on the anterior lower legs in granuloma annulare?

Answer 58

Ultrasound might show a hypoechoic area in the subcutaneous tissues.

Question 59

What findings are expected on radiographs for granuloma annulare?

Answer 59

A nonspecific soft tissue mass without calcification or bone involvement.

Question 60

What findings are expected on MRI for granuloma annulare?

Answer 60

A mass with indistinct margins, isointense or slightly hyperintense to muscle on T1-weighted images.

Question 61

What conditions should be considered in the differential diagnosis of Annular Granuloma?

Answer 61

Tinea corporis, subacute cutaneous lupus erythematosus, neonatal lupus erythematosus, annular lichen planus.

Question 62

What conditions should be ruled out in the differential diagnosis of Annular Granuloma?

Answer 62

Infections such as tuberculosis and syphilis, interstitial granulomatous drug reaction, and lymphoma.

Question 63

What conditions should be considered in the differential diagnosis of Generalized Granuloma Annulare?

Answer 63

Lichen planus, lichen nitidus, molluscum contagiosum.

Question 64

What conditions should be considered in the differential diagnosis of Subcutaneous Granuloma Annulare?

Answer 64

Erythema nodosum, dermoid cyst, rheumatoid nodules.

Question 65

What conditions should be considered in the differential diagnosis of Perforating Granuloma Annulare?

Answer 65

Molluscum contagiosum, insect bites, perforating collagenosis.

Question 66

What conditions should be considered in the differential diagnosis of Perforating Granuloma Annulare?

Answer 66

Conditions to consider include: - Molluscum contagiosum - Insect bites - Pityriasis lichenoides - Perforating collagenosis and other perforating disorders - Foreign body granuloma - Pauciimmune tuberculid - Palisaded neutrophilic and granulomatous dermatitis of immune complex disease

Question 67

What conditions should be considered in the differential diagnosis of Patch Type Granuloma Annulare?

Answer 67

Conditions to consider include: - Morphea - Erythema annulare centrifugum - Parapsoriasis ## Footnote Conditions to rule out: Lymphoma

Question 68

What conditions should be considered in the differential diagnosis of Annular Granuloma?

Answer 68

Conditions to consider include: - Tinea corporis - Subacute cutaneous lupus erythematosus - Neonatal lupus erythematosus - Annular lichen planus - Acute febrile neutrophilic dermatosis - Erythema chroium migrans - Actinic granuloma/annular elastolytic giant cell granuloma - Necrobiosis lipoidica diabeticorum

Question 69

What conditions should be ruled out when diagnosing Generalized Granuloma Annulare?

Answer 69

Conditions to rule out include: - Lichen planus and granulomatous dermatitis of acquired immunodeficiency syndrome - Molluscum contagiosum - Infections (e.g., tuberculosis, atypical mycobacteria, syphilis) - Sarcoidosis - Familial granulomatous arthritis, skin eruptions, and uveitis - Interstitial granulomatous drug reaction - Lymphoma

Question 70

What conditions should be considered in the context of Subcutaneous Granuloma Annulare?

Answer 70

Consider: - Erythema nodosum - Dermoid cyst - Rheumatoid nodules ## Footnote Rule Out: Epitheloid sarcoma, Benign or other malignant tumors, Deep infections

Question 71

What conditions are included in the differential diagnosis for the Perforating Type of Granuloma Annulare?

Answer 71

Conditions to consider include: - Molluscum contagiosum - Insect bites - Pityriasis lichenoides - Perforating collagenosis and other perforating disorders - Foreign body granuloma - Pauciimmune tuberculid - Palisaded neutrophilic and granulomatous dermatitis of immune complex disease

Question 72

What should be considered and ruled out in the diagnosis of Patch Type Granuloma Annulare?

Answer 72

Consider: - Morphea - Erythema annulare centrifugum - Parapsoriasis ## Footnote Rule Out: Lymphoma

Question 73

GA occurs more often in what demographic?

Answer 73

children and young adults

Question 74

What form of GA is common in children and young adults?

Answer 74

annular and subcutaneous

Question 75

What form of GA is common in adults?

Answer 75

generalized/disseminated

Question 76

This feature is typical in GA.

Answer 76

A localized ring of beaded papules on the extremities

Question 77

What is the common form of localized GA and its most common locations?

Answer 77

Annular dorsal hands and feet, lower limbs, wrists > eyelids, palms, soles

Question 78

Most common area/s of involvement of generalized GA?

Answer 78

Trunk, neck, extremities

Question 79

Most common area/s of involvement of subcutaneous GA? What are some disease associations?

Answer 79

Anterior lower legs / pretibial Other sites: ankles, dorsal feet, buttocks, hands, penis Malignancy Rheumatoid disease

Question 80

Most common area/s of involvement of localized and generalized perforating GA?

Answer 80

Localized: dorsal hands and fingers Generalized: trunk and extremities

Question 81

This type of GA has been described on the ears, scrotum, and within herpes zoster scars and tattoos.

Answer 81

Perforating

Question 82

Patch GA are commonly found in _____.

Answer 82

adult women

Question 83

Oral involvement of GA has been observed with this disease association.

Answer 83

HIV

Question 84

Dyslipidemia is associated with this type of GA.

Answer 84

Generalized

Question 85

What are the clinical variants of GA?

Answer 85

Localized Generalized Subcutaneous Perforating Patch

Question 86

Papular umbilicated GA is mostly seen in _____.

Answer 86

children

Question 87

Predisposing events of GA (4)?

Answer 87

1. Trauma 2. Sun exposure 3. Drugs 4. Infections and Immunizations

Question 88

Type of GA seen in tattoos?

Answer 88

Perforating

Question 89

_____ a.k.a. _____, develops on photodamaged skin and is believed to represent a granulomatous reaction to actinic elastosis.

Answer 89

Actinic granuloma Annular elastolytic giant cell granuloma

Question 90

Systemic disorders associated with GA?

Answer 90

"DDTM" 1. DM type 1 2, Dyslipidemia 3. Thyroid disease (thyroiditis, hypothyroidism, adenoma) 4. Malignancy (Hodgkin / Non-Hodgkin lymphoma, leukemia)

Question 91

Drugs associated with GA?

Answer 91

Question 92

Most GA cases resolve spontaneously without sequelae, clearing within a few weeks. Majority disappear within ___ years.

Answer 92

2

Question 93

This GA variant has a more protracted course.

Answer 93

Generalized

Question 94

This GA variant causes scarring.

Answer 94

Perforating

Question 95

IL triamcinolone dose for GA?

Answer 95

2.5 mg/ml

Question 96

Treatment for GA (3)?

Answer 96