34: Granuloma Annulare Flashcards
What is the most common form of granuloma annulare and its characteristics?
The most common form is localized granuloma annulare, characterized by annular or arcuate lesions, skin colored, erythematous, or violaceous, measuring 1 to 5 cm in diameter. The annular margin is firm to palpation and may be continuous or consist of discrete or coalescent papules. Within the annular ring, the skin may have a violaceous or pigmented appearance. Solitary firm papules or nodules may also be present, with papular lesions on the fingers appearing umbilicated.
What are the common sites of predilection for localized granuloma annulare lesions?
Common sites include dorsal hands and feet, ankles, lower limbs, wrists, and less commonly eyelids, palms, and soles.
What distinguishes generalized granuloma annulare from localized forms?
Generalized granuloma annulare occurs in 8% to 15% of cases, primarily in adults, and is characterized by widespread papules that may coalesce into small annular plaques or larger discolored patches. Common sites include the trunk, neck, extremities, and may affect the face, scalp, palms, and soles. Lesions may appear skin colored, pink, violaceous, tan, or yellow.
What are the characteristics and common sites of subcutaneous granuloma annulare?
Subcutaneous granuloma annulare predominantly occurs in children and is characterized by firm to hard, usually asymptomatic nodules located in the deep dermis and subcutaneous tissues, measuring from 6 mm to 3.5 cm in diameter. Common sites include anterior lower legs, ankles, dorsal feet, buttocks, hands, and may also be found on the penis.
What is the rare variant of granuloma annulare and its characteristics?
The rare variant is perforating granuloma annulare, characterized by transepidermal elimination of necrobiotic collagen. Common sites include localized areas on the dorsal hands and fingers and generalized over the trunk and extremities.
What is the most likely diagnosis for a patient with annular lesions on wrists and ankles?
The most likely diagnosis is localized granuloma annulare. Common sites of predilection include dorsal hands and feet, ankles, lower limbs, and wrists.
What subtype of granuloma annulare is characterized by firm, asymptomatic nodules on the anterior lower legs?
This is subcutaneous granuloma annulare. Other sites that might be involved include ankles, dorsal feet, buttocks, hands, and occasionally the penis.
What subtype of granuloma annulare is characterized by widespread papules that coalesce into annular plaques?
This is generalized granuloma annulare, which typically has a more protracted course compared to localized granuloma annulare.
What variant of granuloma annulare might be represented by umbilicated papular lesions on the fingers?
This might represent papular umbilicated granuloma annulare. Common sites of predilection for localized granuloma annulare include dorsal hands and feet, ankles, lower limbs, and wrists.
What subtype of granuloma annulare might represent painful nodular lesions on the feet?
This might represent subcutaneous granuloma annulare, which is usually asymptomatic, but painful lesions are rare and may cause discomfort from footwear.
What variant of granuloma annulare is characterized by central ulceration and discharge of creamy fluid?
This is perforating granuloma annulare, with its hallmark feature being transepidermal elimination of necrobiotic collagen.
What are the common clinical features of localized granuloma annulare?
Localized granuloma annulare is characterized by annular or arcuate lesions that are skin colored, erythematous, or violaceous, measuring 1 to 5 cm in diameter, with firm annular margins. The skin within the annular ring may have a violaceous or pigmented appearance.
What distinguishes generalized granuloma annulare in terms of presentation and demographics?
Generalized granuloma annulare occurs in 8% to 15% of cases, primarily affecting adults, and is characterized by widespread papules that may coalesce into small annular plaques or larger discolored patches.
How does subcutaneous granuloma annulare typically present?
It presents as firm to hard, usually asymptomatic nodules located in the deep dermis and subcutaneous tissues, measuring from 6 mm to 3.5 cm in diameter.
What are the characteristics and common sites of predilection for perforating granuloma annulare?
Perforating granuloma annulare is characterized by transepidermal elimination of necrobiotic collagen, commonly localized to the dorsal hands and fingers or generalized over the trunk and extremities.
What are the common clinical variants of granuloma annulare?
Common clinical variants include papular umbilicated granuloma annulare on the hands of children and generalized follicular pustular type of granuloma annulare.
What noncutaneous findings are associated with granuloma annulare?
Most patients are healthy with no other abnormal physical findings. Arthralgia is reported in association with painful lesions on the hands.
What are some potential triggering factors for granuloma annulare?
Potential triggers include nonspecific mild trauma, insect/animal bite reactions, long-standing tattoos, and widespread lesions from waxing-induced pseudofolliculitis.
How is granuloma annulare linked to systemic diseases?
It is primarily associated with type 1 diabetes mellitus, but also reported in type 2 DM, thyroiditis, hypothyroidism, and thyroid adenoma.
What is the pathogenesis of granuloma annulare?
The pathogenesis involves a primary degenerative process of connective tissue initiating granulomatous inflammation, a lymphocyte-mediated immune reaction, and a subtle vasculitis or other microangiopathy leading to tissue injury.
What are the potential triggers for granuloma annulare in patients with HIV?
Potential triggers include photosensitivity, herpes zoster scars, and generalized disease after PUVA light therapy.
What systemic diseases are associated with granuloma annulare in relation to diabetes?
Systemic diseases include diabetes mellitus (primarily type 1 but also type 2) and thyroid disease, with various forms of granuloma annulare observed in diabetic patients.
What infections or immunizations have been linked to granuloma annulare?
Infections linked include herpes zoster scars, chickenpox, HIV infection, Epstein-Barr virus, chronic hepatitis B and C, and vaccinations such as diphtheria toxoid and BCG immunization.
What is the relationship between thyroid disease and granuloma annulare?
Granuloma annulare has been observed in patients with thyroiditis, hypothyroidism, and thyroid adenoma.
What phenomenon might explain granuloma annulare lesions developing after waxing-induced pseudofolliculitis?
This might be explained by the Koebner phenomenon, where trauma induces lesions.
What variant of granuloma annulare might represent lesions on photodamaged skin?
This might represent annular elastolytic giant cell granuloma, a reaction to actinic elastosis on photodamaged skin.
What drugs have been implicated in triggering granuloma annulare?
Drugs include gold therapy, allopurinol, diclofenac, quinidine, intranasal calcitonin, topiramate, amlodipine, thalidomide, adalimumab, infliximab, etanercept, efalizumab, and vemurafenib.
What systemic phenomenon might explain granuloma annulare lesions developing after a scabies infestation?
This might be attributed to the Koebner phenomenon, where trauma or irritation induces lesions.
What are the clinical variants of granuloma annulare observed in children and adults?
In children, papular umbilicated granuloma annulare on the hands is common, while adults may present with generalized follicular pustular type of granuloma annulare.
How does trauma contribute to the development of granuloma annulare in children?
Nonspecific mild trauma is a possible triggering factor, along with insect/animal bite reactions, long-standing tattoos, and widespread lesions after waxing-induced pseudofolliculitis.
What systemic diseases are associated with granuloma annulare, particularly in relation to diabetes and thyroid conditions?
Diabetes Mellitus is primarily linked with type 1 DM, but cases are also reported with type 2 DM. Granuloma annulare has been observed in patients with thyroiditis, hypothyroidism, and thyroid adenoma.
What are the potential drug-related triggers for granuloma annulare?
Potential triggers include gold therapy and treatments with allopurinol, diclofenac, quinidine, intranasal calcitonin, topiramate, amlodipine, thalidomide, and various biologics.
What is intranasal calcitonin?
A medication used for various conditions, including osteoporosis.
What is topiramate?
An anticonvulsant medication used to treat epilepsy and prevent migraines.
What is amlodipine?
A calcium channel blocker used to treat high blood pressure and chest pain.
What is thalidomide?
A medication used to treat certain cancers and leprosy complications.
What are biologics?
Medications derived from living organisms, including adalimumab, infliximab, etanercept, efalizumab, and vemurafenib.
What may mimic granuloma annulare?
Angiotensin-converting enzyme inhibitors and calcium channel blockers.
What is the pathogenesis of granuloma annulare?
- A primary degenerative process of connective tissue initiating granulomatous inflammation.
- A lymphocyte-mediated immune reaction resulting in macrophage activation and cytokine-mediated degradation of connective tissue.
- A subtle vasculitis or other microangiopathy leading to tissue injury.
What types of malignancies can mimic granuloma annulare?
Hodgkin lymphoma, Non-Hodgkin lymphoma, Mycosis fungoides, Lennert lymphoma, B-cell disease, T-cell leukemia and lymphoma, Angioblastic T-cell lymphoma.
What is a characteristic histopathologic finding in generalized granuloma annulare?
Lymphohistiocytic granuloma associated with varying degrees of connective tissue degeneration and mucin deposition.
What are the histopathologic features of necrobiosis in granuloma annulare?
Single or multiple foci of inflammation with a central core of altered collagen surrounded by a wall of palisaded histiocytes.
What laboratory tests are important in the diagnosis of granuloma annulare?
Skin biopsy to confirm diagnosis and positive stains for mucin and lipid to support diagnosis.
What are the clinical implications of dyslipidemia in patients with granuloma annulare?
Increased prevalence of dyslipidemia has been reported in patients with granuloma annulare, particularly in cases with an annular morphology.
What is the significance of immunofluorescence testing in granuloma annulare?
Immunofluorescence testing may show deposition of fibrin IgM and C3 around vessel walls or at the basement membrane zone.
What laboratory tests might be considered for generalized granuloma annulare?
Lipid studies might be considered, especially in cases with an annular morphology.
What malignancies are associated with granuloma annulare?
Hodgkin lymphoma, non-Hodgkin lymphoma, mycosis fungoides, and various leukemias.
What are the characteristic histopathologic findings for generalized granuloma annulare?
Lymphohistiocytic granulomas associated with connective tissue degeneration and mucin deposition.
What is the relationship between dyslipidemia and granuloma annulare?
There is an increased prevalence of dyslipidemia in patients with granuloma annulare, particularly in cases with an annular morphology.
What findings might be observed in immunofluorescence testing for granuloma annulare?
Deposition of fibrin, IgM, and C3 around vessel walls or at the basement membrane zone.
What histopathologic pattern is typically observed in generalized granuloma annulare?
An interstitial, nonpalisaded pattern of inflammation with histiocytes infiltrating among fragmented collagen bundles.
What are the clinical implications of distinguishing between granuloma annulare and cutaneous lymphoma?
- Treatment approaches differ; granuloma annulare is often self-limiting.
- Prognosis varies; granuloma annulare generally has a better prognosis.
- Diagnostic procedures may require different techniques.
- Follow-up intensity differs.
How does the histopathologic finding of necrobiosis in granuloma annulare differ from other granulomatous diseases?
It features a central core of altered collagen surrounded by palisaded histiocytes, which is distinct from other granulomatous diseases.
What are the key laboratory tests for diagnosing generalized granuloma annulare?
- Skin biopsy for diagnosis confirmation.
- Stains for mucin and lipid to support diagnosis.
- Lipid studies for dyslipidemia evaluation.
- Immunofluorescence testing for differentiation.
What imaging studies may be performed for subcutaneous granuloma annulare?
Radiographs, ultrasound, and MRI.
What is the typical course and prognosis for localized granuloma annulare?
Typically resolves spontaneously without sequelae, may clear within a few weeks or persist for several years.
What are the treatment options for granuloma annulare?
Treatment options include intralesional, systemic, and other therapies.
What imaging modality might be used for lesions on the anterior lower legs in granuloma annulare?
Ultrasound might show a hypoechoic area in the subcutaneous tissues.
What findings are expected on radiographs for granuloma annulare?
A nonspecific soft tissue mass without calcification or bone involvement.
What findings are expected on MRI for granuloma annulare?
A mass with indistinct margins, isointense or slightly hyperintense to muscle on T1-weighted images.
What conditions should be considered in the differential diagnosis of Annular Granuloma?
Tinea corporis, subacute cutaneous lupus erythematosus, neonatal lupus erythematosus, annular lichen planus.
What conditions should be ruled out in the differential diagnosis of Annular Granuloma?
Infections such as tuberculosis and syphilis, interstitial granulomatous drug reaction, and lymphoma.
What conditions should be considered in the differential diagnosis of Generalized Granuloma Annulare?
Lichen planus, lichen nitidus, molluscum contagiosum.
What conditions should be considered in the differential diagnosis of Subcutaneous Granuloma Annulare?
Erythema nodosum, dermoid cyst, rheumatoid nodules.
What conditions should be considered in the differential diagnosis of Perforating Granuloma Annulare?
Molluscum contagiosum, insect bites, perforating collagenosis.
What conditions should be considered in the differential diagnosis of Perforating Granuloma Annulare?
Conditions to consider include:
- Molluscum contagiosum
- Insect bites
- Pityriasis lichenoides
- Perforating collagenosis and other perforating disorders
- Foreign body granuloma
- Pauciimmune tuberculid
- Palisaded neutrophilic and granulomatous dermatitis of immune complex disease
What conditions should be considered in the differential diagnosis of Patch Type Granuloma Annulare?
Conditions to consider include:
- Morphea
- Erythema annulare centrifugum
- Parapsoriasis
Conditions to rule out: Lymphoma
What conditions should be considered in the differential diagnosis of Annular Granuloma?
Conditions to consider include:
- Tinea corporis
- Subacute cutaneous lupus erythematosus
- Neonatal lupus erythematosus
- Annular lichen planus
- Acute febrile neutrophilic dermatosis
- Erythema chroium migrans
- Actinic granuloma/annular elastolytic giant cell granuloma
- Necrobiosis lipoidica diabeticorum
What conditions should be ruled out when diagnosing Generalized Granuloma Annulare?
Conditions to rule out include:
- Lichen planus and granulomatous dermatitis of acquired immunodeficiency syndrome
- Molluscum contagiosum
- Infections (e.g., tuberculosis, atypical mycobacteria, syphilis)
- Sarcoidosis
- Familial granulomatous arthritis, skin eruptions, and uveitis
- Interstitial granulomatous drug reaction
- Lymphoma
What conditions should be considered in the context of Subcutaneous Granuloma Annulare?
Consider:
- Erythema nodosum
- Dermoid cyst
- Rheumatoid nodules
Rule Out: Epitheloid sarcoma, Benign or other malignant tumors, Deep infections
What conditions are included in the differential diagnosis for the Perforating Type of Granuloma Annulare?
Conditions to consider include:
- Molluscum contagiosum
- Insect bites
- Pityriasis lichenoides
- Perforating collagenosis and other perforating disorders
- Foreign body granuloma
- Pauciimmune tuberculid
- Palisaded neutrophilic and granulomatous dermatitis of immune complex disease
What should be considered and ruled out in the diagnosis of Patch Type Granuloma Annulare?
Consider:
- Morphea
- Erythema annulare centrifugum
- Parapsoriasis
Rule Out: Lymphoma
GA occurs more often in what demographic?
children and young adults
What form of GA is common in children and young adults?
annular and subcutaneous
What form of GA is common in adults?
generalized/disseminated
This feature is typical in GA.
A localized ring of beaded papules on the extremities
What is the common form of localized GA and its most common locations?
Annular
dorsal hands and feet, lower limbs, wrists > eyelids, palms, soles
Most common area/s of involvement of generalized GA?
Trunk, neck, extremities
Most common area/s of involvement of subcutaneous GA? What are some disease associations?
Anterior lower legs / pretibial
Other sites: ankles, dorsal feet, buttocks, hands, penis
Malignancy
Rheumatoid disease
Most common area/s of involvement of localized and generalized perforating GA?
Localized: dorsal hands and fingers
Generalized: trunk and extremities
This type of GA has been described on the ears, scrotum, and within herpes zoster scars and tattoos.
Perforating
Patch GA are commonly found in _____.
adult women
Oral involvement of GA has been observed with this disease association.
HIV
Dyslipidemia is associated with this type of GA.
Generalized
What are the clinical variants of GA?
Localized
Generalized
Subcutaneous
Perforating
Patch
Papular umbilicated GA is mostly seen in _____.
children
Predisposing events of GA (4)?
- Trauma
- Sun exposure
- Drugs
- Infections and Immunizations
Type of GA seen in tattoos?
Perforating
_____ a.k.a. _____, develops on photodamaged skin and is believed to represent a granulomatous reaction to actinic elastosis.
Actinic granuloma
Annular elastolytic giant cell granuloma
Systemic disorders associated with GA?
“DDTM”
1. DM type 1
2, Dyslipidemia
3. Thyroid disease (thyroiditis, hypothyroidism, adenoma)
4. Malignancy (Hodgkin / Non-Hodgkin lymphoma, leukemia)
Drugs associated with GA?
Most GA cases resolve spontaneously without sequelae, clearing within a few weeks. Majority disappear within ___ years.
2
This GA variant has a more protracted course.
Generalized
This GA variant causes scarring.
Perforating
IL triamcinolone dose for GA?
2.5 mg/ml
Treatment for GA (3)?
