Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
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Hilmi F. Recica and Andrew Ilchyshyn
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Granuloma annulare (GA) is usually a benign and self limiting skin disease of unknown etiology. There are a number of variants: localized, generalized or disseminated, subcutaneous, papulo-pustular and perforating. It is characterized histologically by palisading granulomata with a central core of necrobiotic or degenerative collagen surrounded by a lympho-histiocytic infiltrate. The disease often resolves spontaneously, with no long term sequelae.
The localized variant of GA is often diagnosed clinically, but a skin biopsy may be required to confirm the diagnosis of the more unusual varieties such as generalized, papulo-pustular, perforating, and subcutaneous forms. Once the diagnosis is established, it is prudent to check the urine for glucose to exclude diabetes mellitus. In disseminated and generalized variants HIV, hepatitis C, and lymphomas are rare associations.
Because the majority of cases of GA are asymptomatic and self limiting, the need for active treatment should be considered carefully; in many cases, reassurance that the disease is benign and will resolve spontaneously is sufficient. Painful or unsightly lesions may justify more active treatment, though the evidence to support the efficacy of many of the treatments is poor.
Localized GA may be treated effectively with topical or intralesional steroids. Clobetasol propionate (Dermovate) lotion under occlusion with a hydrocolloid dressing, changed weekly, can be used for up to 6 weeks. Alternatively, intralesional injections of triamcinolone may be used, at intervals of 6 to 8 weeks. Cryotherapy using liquid nitrogen can be repeated at 3 or 4 weeks if required. Treatment of refractory lesions includes photodynamic therapy, UVA1, intralesional interferon; large, tumid lesions may require excision.
Generalized GA may be persistent and its unsightly appearance causes patients to seek active treatment, though the results are often disappointing. Both UVA and PUVA may be used, but relapses can occur. Isotretinoin and dapsone have been associated with improvement or clearance of generalized GA. Topical tacrolimus and pimecrolimus have been used, with greater success in generalized disease than in the localized variety. Other reported treatments for this condition include laser, fumaric acid esters, hydroxychloroquine, chlorambucil, cyclosporine, hydroxyurea, doxycycline, systemic steroids, adalimumab, infliximab, anthralin, vitamin E, allopurinol, nicotinamide, pentoxifylline, and defibrotide.
Check urine for glucose
Unlike necrobiosis lipoidica, in which there is a strong association with diabetes mellitus, the relationship between GA and diabetes is unclear. Nevertheless, it would seem sensible to use the diagnosis of GA as a cue to exclude undiagnosed diabetes, and at least check the urine for glucose.
Carbohydrate tolerance in patients with granuloma annulare. Study of fifty two cases.
Haim S, Friedman-Birnbaum R, Haimn Shafrir A, Ravina A. Br J Dermatol 1973; 88: 447–51.
In a study of 39 patients with localized GA the incidence of abnormal carbohydrate tolerance was 23% and similar to that of a control population, compared to an incidence of 77% in 13 patients with generalized disease.
Absence of carbohydrate intolerance in patients with granuloma annulare.
Gannon TF, Lynch PJ. J Am Acad Dermatol 1994; 30: 662–3.
In a study of 23 patients with GA, 13 patients had localized lesions and 10 patients had generalized form of the disease; glycosylated haemoglobin levels were found to be normal.
Localised granuloma annulare is associated with insulin-dependent diabetes mellitus.
Muhlemann MF, Williams DR. Br J Dermatol 1984; 111: 325–9.
This retrospective study looked at 557 insulin-dependent diabetics and found that 16 patients had GA, significantly more than the 0.9 cases that might have been expected.
Granuloma annulare and necrobiosis lipoidica treated by jet injector.
Sparrow G, Abell E. Br J Dermatol 1975; 93: 85–9.
In this study of 45 patients with GA, intralesional triamcinolone produced a complete response in 68% of patients after three treatments carried out at 6- and 8-week intervals. About half of the patients suffered recurrences, which responded to re-treatment.
Successful outcome of cryosurgery in patients with granuloma annulare.
Blume-Peytavi U, Zouboulis CH, Jacobi H, Scholz A, Bisson S, Orfanos CE. Br J Dermatol 1994; 130: 494–7.
In a study of 31 patients with GA, 22 patients were treated with liquid nitrogen and nine with nitrous oxide. After a single freeze – thaw cycle 81% of lesions were cleared. Four cases had persistent atrophic scars, where large lesions had been treated with liquid nitrogen.
It should be possible to prevent cryo-atrophy by avoiding freeze-thaw cycles of more than 10 seconds, and taking care not to overlap treatment areas.
Successful treatment of chronic skin diseases with clobetasol propionate and a hydrocolloid occlusive dressing.
Volden G. Acta Derm Venereol 1992; 72: 69–71.
One of three cases of GA showed a complete response after 4 weeks of treatment with clobetasol propionate under occlusion.
This treatment has the advantage of being painless, but evidence for its efficacy is not strong.
Treatment of granuloma annulare with the 595 nm pulsed dye laser (PDL), a multicentre retrospective study with long-term follow-up.
Passeron T, Fusade T, Vabres P, Bousquet-Rouaud R, Collet-Vilette A-M, et al. J Eur Acadol 2011 [E-pub].
In this study, five patients with localized and eight with generalized GA were treated with three sessions of pulsed-dye laser. A significant response was only seen in the localized forms.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
Intralesional steroids
Cryotherapy
Topical steroids
Laser
Photodynamic therapy
Imiquimod
UVA1
Interferon
Scarification
Surgery
Rifampin, ofloxacin, minocycline combination
