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What is Granuloma Annulare?
Granuloma annulare (GA) is not an uncommon skin condition. As dermatologists, we tend to diagnose and treat this condition routinely. It is not contagious and tends to be self-limited in many cases. As many as two-thirds of the diagnoses tend to occur before the age of 30. Although its true cause is unknown, it is thought to be a ‘reactive’ skin condition. In other words, it is believed to be triggered by something- for example, some cases can occur after even a mild viral infection. It is not an allergic reaction. Even though it is believed to be triggered by a cause, this trigger is not usually clear.
Granuloma annulare is a rash that can develop in the skin and take on a few distinct appearances. It may be underdiagnosed as it does not necessarily have symptoms when noted. It is not an infectious rash and represents inflammation in the skin that can take on a distinct appearance on skin biopsies.
The word “granuloma” refers to the appearance of these skin lesions under the microscope. “Annulare” references the distinct annular or ring-like appearance the rash can appear on the skin.
It is considered to be benign and not contagious.
What does Granuloma Annulare (GA) look like?
There are 4 classic appearances that GA can take.
- Localized. Reddish papules or bumps develop in the skin and may start to group and form rings or larger plaques. There is not usually scaling, roughness, itching associated. They are smooth and somewhat firm or indurated when touched. They are usually on the arms, legs, hands, or feet but can present anywhere on the skin. This version represents most cases of GA, as many as 75% of cases. According to medical reviews, about half of the cases last around 2 years with or without treatment however it can last longer in individuals.
- Disseminated or generalized. This appears similar to localized but is more widespread. This version comprises about 10% of cases and may last longer than localized variants. This can last 3 to 4 years if not longer.
- Subcutaneous. This occurs mostly in children below the age of 5. Unlike the first two variants, this variant is deeper and presents as nodules that are subcutaneous and may enlarge. It tends to resolve spontaneously.
- Perforating. This variant is different from the other types in that it can be associated with scaling or crusting with evidence of collagen “perforating” through the skin. Itching may be associated as well.
What is granuloma annulare most commonly mistaken for?
Perhaps the most common rash that GA can be mistaken for is tinea corporis or ringworm. The two features that tend to distinguish GA are that GA does not tend to be itchy or scaly. Ringworm tends to be both.
Is granuoma annulare contagious?
GA is not considered contagious. It is an inflammatory condition in the skin.
How is granuloma annulare diagnosed?
Granuloma annulare can be diagnosed clinically by a Board Certified Dermatologist given expertise and experience in diagnosing and treating this condition. If a diagnosis is uncertain, a biopsy can be obtained as there are classic histologic findings that can confirm the diagnosis.
How is granuloma annulare treated?
We tend to focus on managing the skin to help our patients control this skin condition. Of note, if once I explain to patients the nature of this condition they choose not to treat the skin- this is ok! Treating the individual lesions does not prevent new spots from developing.
It is always important for our patients to feel empowered to decide for themselves if and how to approach GA. Localized GA is often treated with cyclic topical steroids or injection of steroids into individual lesions. We often start with topical steroids or nonsteroidal creams. These can work well to help manage the individual lesions. They work in stages- first, the lesions flatten, then they may start to fade. If topicals do not work, we can consider intralesional injections of steroids.
Beyond these interventions, the discussion with your dermatologist on the next steps is important to weigh the risks and benefits of each option. We would want to make sure that the treatment does not cause more harm than the GA itself. Systemic therapy options for GA for disseminated disease include dapsone, isotretinoin, hydroxychloroquine, cyclosporine, remicade, or phototherapy. The choice of therapy is decided based on any other health considerations, balancing the risks and benefits of each therapeutic, and discussing with your Dermatologist.
If we decide to avoid oral medications, we have seen success with in-office phototherapy. Treatments 2 to 3 x weekly can be beneficial. Beyond this, there are oral medications such as hydroxychloroquine, isotretinoin, tetracyclines, dapsone, and rifampin. I tend to approach this discussion by working on individualized recommendations based on other medications they may be on. Treatment is not always necessary for granuloma annulare as it may be self-limited. Treatment only hastens the resolution of individual lesions but does not necessarily prevent new lesions from developing unless systemic therapy is tried.