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GRANULOMA ANNULARE

Granuloma annulare is a harmless skin condition that only causes cosmetic blemishes of reddish circle like papules or plaques with centrally placed cleared skin.  These circles can merge and produce geographical patterns.  Two types are commonly described apart from other rare types.

   Granuloma Annulare is a benign self limiting dermatosis of unknown cause characterised usually by annular rings of small flesh coloured papules. Four different clinical manifestations are recognised: localised, generalised, perforating, and subcutaneous type.  Localised Granuloma annulare is the most common form and spontaneous resolution occurs in 50% of patients however the lesions may take upto 2 years to resolve. The generalised form  is often difficult to treat, spontaneous resolution is less common  and rare before 3-4 years.

1. Localized

One to ten circle red rings with raised wall like borders and central normal skin.

2. Generalized

More numerous, literally hundreds of small annular papules dominate the skin surface.  Others – perforating type, subcutaneous type causes.  All the below are theories

1. sunlight & sun exposure
2. insect bite
3. trauma

The widespread type can be associated with diabetes mellitus hence your doctor may choose to look for diabetes.

Course

Most of the lesions settle with time except the generalized type, which has a rather unpredictable course.

Investigation

1. A skin biopsy may be carried to confirm the diagnosis.
2. Blood tests to exclude diabetes.

Treatment

1. Intralesional steroids injection
2. intralesional saline injection
3. chloroquine
4. retinoids
5. photo therapy  

 Latest Update

  Granuloma Annulare is a benign self limiting dermatosis of unknown cause characterised usually by annular rings of small flesh coloured papules. Four different clinical manifestations are recognised: localised, generalised, perforating, and subcutaneous type.  Localised Granuloma annulare is the most common form and spontaneous resolution occurs in 50% of patients however the lesions may take upto 2 years to resolve. The generalised form  is often difficult to treat, spontaneous resolution is less common  and rare before 3-4 years.

Generalised Granuloma annulare  presents with hundreds or thousands of relatively small 1-2 mm glossy skin coloured papules. The papules may remain solitary or coalesce. Generalised Granuloma annulare differs from the localised form by a later age of onset,protracted course with only rare spontaneous resolution , poor response to therapy and an increase prevalence of HLA Bw 35. A delayed type of Hypersensitivity is believed to play a role but the aetiology is far from clear. 

Various treatments  tried include topical and systemicsteroids,cryotherapy,dapsone,chlorambucil,methotrexate,isotretinoin, PUVA, hydroxychloroquine,   pentoxyfilline, salicylates,  dipyrimiadole, colchicine  ,niacinamide, chlorpropamide, sulfonylureas,isotretinoin,  tranilast,  Beta interferon,  potassium iodide.  Among these hydroxychloroquine retinoids, PUVA,TLO1UVB  and cyclosporin,  have  been used with complete resolution in the patients treated.

 TLO1UVB  has  the added advantage that it does not  require psoralen tablets and spares the  attendant side effects. It is however interesting to note that while ultraviolet light is proposed as one of the etiologic factors ultraviolet light  also helps to resolve the condition. TLO1 UVB phototherapy may be used as an another   effective treatment option  for  generalised granuloma annulare.

for info on TLO1UVB click here