Granuloma annulare (GA) is a benign granulomatous inflammatory disorder of the dermis or subcutis. Its cause is unknown. Small dermal papules may present in isolation or coalesce to form smooth annular plaques, often on extremities. Lesions are typically asymptomatic or only mildly pruritic, but the appearance may cause patients distress. The disease is more common in women (female-to-male ratio of 2:1), and two-thirds of patients are aged younger than 30. The disease usually resolves spontaneously with no adverse sequelae, though some cases prove persistent or recurrent.
Some reports in the literature have suggested that GA is associated with certain triggers or systemic diseases, most commonly diabetes mellitus; other diseases that may be associated include thyroid disease, dyslipidemia, malignancy, and infections.
There are 3 principal variants of GA: localized (75% of cases), generalized (or disseminated), and subcutaneous (also known as pseudo-rheumatoid nodules). Patch GA is a variant of localized GA in which the plaques are extremely thin and barely palpable. A fourth type – perforating GA – refers to rare lesions that demonstrate histologic evidence of transepidermal extrusion of degraded collagen. Actinic granuloma presents with similar lesions and is thought by some to represent GA occurring in sun-damaged skin. Palmoplantar GA is a rare variant favoring the palms.
Codes
ICD10CM: L92.0 – Granuloma annulare
SNOMEDCT: 65508009 – Granuloma annulare
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Differential Diagnosis & Pitfalls
GA is often mistaken for dermatophyte infection (tinea corporis, or "ringworm"). The presence of scale in dermatophyte infection should allow the distinction.
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
Granuloma annulare is a common skin condition that appears as papules (small, solid bumps) that may form smooth, ring-shaped plaques (flat areas that are larger than a thumbnail), often over the joints and the backs of the hands. The cause is not known, and most episodes of granuloma annulare clear up after a few years, with or without treatment.
Who’s At Risk
Although granuloma annulare can occur in people of any race / ethnicity and at any age, it is most commonly seen in children and young adults. Females are slightly more likely than males to develop granuloma annulare.
Signs & Symptoms
Granuloma annulare occurs most frequently over the joints or in areas that experience mild injury. The most common locations for granuloma annulare include:
The backs of the hands and tops of the fingers.
The tops of the feet.
Around the elbows.
Around the knees.
However, other areas of the skin may also be affected. The lesions of granuloma annulare are usually found in the same areas on both sides of the body (symmetrically).
Granuloma annulare appears as papules that may occur singly or in groups and that may form ring-shaped plaques. The center of the plaque may be lighter or darker than your normal skin color. Healed lesions of granuloma annulare do not leave scars.
Granuloma annulare does not usually have any symptoms, although in some individuals, the lesions may be itchy.
Rarely, granuloma annulare may be widespread, known as generalized granuloma annulare. Generalized granuloma annulare tends to occur in adults aged 30 and older. The condition may consist of 1-2 mm papules that appear on the arms, legs, and upper trunk.
Granuloma annulare may be skin-colored in skin of any color; it may appear pink, light brown, red-brown, or light purple in lighter skin colors; or it may be pink, brown, or purple in darker skin colors.
Self-Care Guidelines
Because granuloma annulare is usually asymptomatic, no self-care measures are generally needed. If the lesions are itchy, though, an over-the-counter cortisone (eg, Cortaid) cream may be helpful.
When to Seek Medical Care
If you have bumps or ring-shaped lesions on your skin for more than a few weeks, it is a good idea to have them evaluated by a dermatologist or another medical professional.
Treatments
If the diagnosis of granuloma annulare is not obvious, a dermatologist may want to perform a skin biopsy.
Once the diagnosis of granuloma annulare is confirmed, you and your medical professional may decide not to treat it, as many cases of granuloma annulare clear up within 2 years, even without treatment.
If the lesions of granuloma annulare cause discomfort or are widespread or cosmetically bothersome, your medical professional may try one of the following:
A prescription-strength steroid cream.
Steroid injections directly into the lesions or freezing with liquid nitrogen (cryotherapy). In darker skin colors, these treatments may leave an area of lighter skin color.
Generalized granuloma annulare is more stubborn, with fewer cases of spontaneous resolution and more recurrences. In addition, other treatments may be used:
Oral steroids, such as prednisone (Rayos)
Ultraviolet light
Other oral medications such as dapsone, hydroxychloroquine (Plaquenil), or isotretinoin (Amnesteem, Claravis)
Patient Information for Granuloma annulare in Adult