Randy Jacobs, M.D. Patient Education

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Granuloma Annulare


What Is Granuloma Annulare?

 Granuloma annulare is a benign, self-limited disorder affecting the dermis or lower parts of the skin. Granuloma annulare is characterized by cutaneous non-scaled papules often arranged in an annular or ring-like configuration. For this reason, the condition may be mistaken for ring worm. Make no mistake; granuloma annulare is usually smooth surfaced, while ring worm is usually scaly surfaced.


What causes it?

Granuloma annulare’s cause is unknown. Several etiologies have been proposed , but they have been speculative at best. What is known is that granuloma annulare results from changes in the immune system. Granuloma annulare tends to occur primarily in children and in young adults. Granuloma annulare is twice as common in females than in males. It has been known to follow insect bites, sun exposure, trauma, and viral infections. Granuloma annulare may occur in scars. An association between granuloma annulare and diabetes has been shown to occur in generalized granuloma annulare. There may be an association with thyroid disease and there may be a genetic or familial tendency to this condition.


How does it begin?

Granuloma annulare may present in a number of different ways. Localized granuloma annulare is the most common form, and occurs primarily in children and young adults.  Localized granuloma annulare consists of skin-colored, erythematous or violet colored, well-defined dome shaped papules often arranged in a complete or half shaped circle. These lesions most commonly appear on the backs of the hands and feet, but may appear elsewhere on the extremities, with the face and scalp being rarely affected. The lesions never ulcerate and may disappear without a trace. 73% may clear within two years. 25% may persist for many years. The generalized form of granuloma annulare is less common. In the generalized form there are more than ten lesions and there may be hundreds or even thousands of 1 to 2 mm skin colored papules that arise primarily on sun exposed areas of the skin. In contrast to the localized form, the trunk is usually involved and lesions are especially common on the neck and extensor surfaces of the elbows. The face is usually spared. The generalized form of granuloma annulare tends to occur in female patients older than forty. Diabetes has been reported in this type. The generalized form of granuloma annulare persists for an average of 3 to 4 years. Other forms of granuloma annulare include a flat type, nodular type, perforating type, and a multiple form type. As a rule, the lesions of granuloma annulare do not flake, scale, or  ulcerate. However, the less common perforating variant of granuloma annulare may develop central umbilication. Perforating lesions may develop central plugs or crusts.


How does it progress?

The lesions of granuloma annulare may last for a duration of weeks to months to years. In the localized form, there is spontaneous resolution in 73% of patients within 2 years. In the generalized form, spontaneous resolution is rare and lesions may persist for decades. All risks and benefits should be weighed before treating, as therapy may also have side effects.

How is it diagnosed?

Along with the clinical picture, the chief laboratory aid in the diagnosis of granuloma annulare is skin biopsy. Histological examination shows classic findings of granuloma annulare. Based on these findings, Dr. Jacobs will inform you of the diagnosis and will discuss possible treatment methods with you.


How is it treated?

Because granuloma annulare is often self limited and symptomatic treatment is often unnecessary, either injections of triamcinolone or topical corticosteroids under occlusion have proven to be effective in some cases. This treatment does not always work. The major side effect from this type of treatment is skin atrophy (thinning). Treatment of the generalized form of granuloma annulare has been frustrating. Multiple systemic methods have been tried, but the efficacy of these methods have not been proven. Because the lesions are usually not bothersome and are mostly self limited, Dr. Jacobs feels that therapy should be limited only to persistent cosmetically disfiguring lesions.


What to expect from treatment?

Dr. Jacobs believes the first step in treatment should be intelligent patient education. Dr. Jacobs desires his patients to understand the benign, and often self limited nature of granuloma annulare. Patient education is important as the patient learns to deal with granuloma annulare in an appropriate, intelligent,  and medically safe manner.



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