Incidence and Prevalence of Granuloma Annulare in the United States

Skin health of community-living older people: a scoping review

The population of older people is steadily increasing and the majority live at home. Although the home and community are the largest care settings worldwide, most of the evidence on dermatological care relates to secondary and tertiary care. The overall aims were to map the available evidence regarding the epidemiology and burden of the most frequent skin conditions and regarding effects of screening, risk assessment, diagnosis, prevention and treatment of the most frequent skin conditions in older people living in the community. A scoping review was conducted. MEDLINE, Embase and Epistemonikos were systematically searched for clinical practice guidelines, reviews and primary studies, as well as Grey Matters and EASY for grey literature published between January 2010 and March 2023. Records were screened and data of included studies extracted by two reviewers, independently. Results were summarised descriptively. In total, 97 publications were included. The vast majority described prevalence or incidence estimates. Ranges of age groups varied widely and unclear reporting was frequent. Sun-exposure and age-related skin conditions such as actinic keratoses, xerosis cutis, neoplasms and inflammatory diseases were the most frequent dermatoses identified, although melanoma and/or non-melanoma skin cancer were the skin conditions investigated most frequently. Evidence regarding the burden of skin conditions included self-reported skin symptoms and concerns, mortality, burden on the health system, and impact on quality of life. A minority of articles reported effects of screening, risk assessment, diagnosis, prevention and treatment, mainly regarding skin cancer. A high number of skin conditions and diseases affect older people living at home and in the community but evidence about the burden and effective prevention and treatment strategies is weak. Best practices of how to improve dermatological care in older people remain to be determined and there is a particular need for interventional studies to support and to improve skin health at home.

High Intensity Focused Ultrasound (20 MHz) and Cryotherapy as Therapeutic Options for Granuloma Annulare and Other Inflammatory Skin Conditions

INTRODUCTION

In dermatology, inflammatory skin conditions impose a substantial burden worldwide, with existing therapies showing limited efficacy and side effects. This report aims to compare a novel immunological activation induced by hyperthermic 20 MHz high intensity focused ultrasound (HIFU) with conventional cryotherapy. The bioeffects from the two methods are initially investigated by numerical models, and subsequently compared to clinical observations after treatment of a patient with the inflammatory disease granuloma annulare (GA).

METHODS

Clinical responses to moderate energy HIFU and cryotherapy were analysed using numerical models. HIFU-induced pressure and heat transfer were calculated, and a three-layer finite element model simulated temperature distribution and necrotic volume in the skin. Model output was compared to 22 lesions treated with HIFU and 10 with cryotherapy in a patient with GA.

RESULTS

Cryotherapy produced a necrotic volume of 138.5 mm3 at - 92.7 °C. HIFU at 0.3-0.6 J/exposure and focal depths of 0.8 or 1.3 mm generated necrotic volumes up to only 15.99 mm3 at temperatures of 68.3-81.2 °C. HIFU achieved full or partial resolution in all treated areas, confirming its hyperthermic immunological activation effect, while cryotherapy also resolved lesions but led to scarring and dyspigmentation.

CONCLUSION

Hyperthermic immunological activation of 20 MHz HIFU shows promise for treating inflammatory skin conditions as exemplified by GA. Numerical models demonstrate minimal skin necrosis compared to cryotherapy. Suggested optimal HIFU parameters are 1.3 mm focal depth, 0.4-0.5 J/exposure, 1 mm spacing, and 1 mm margin. Further studies on GA and other inflammatory diseases are recommended.

A Rare Association of Disseminated Granuloma Annulare With Recurrent Uveitis

Granuloma annulare is a benign chronic inflammatory granulomatous dermatosis with a variable clinical presentation. The disseminated form of the disease is characterized by a widespread papular eruption, primarily affecting the trunk, neck, and extremities. The development of granuloma annulare in patients with systemic diseases, such as diabetes mellitus, malignancy, or dyslipidemia, has been extensively documented. Still, only a few cases of granuloma annulare associated with recurrent uveitis have been reported. Herein, we present a rare case of generalized granuloma annulare that was associated with concomitant recurrent uveitis in a 60-year-old male patient with a history of type II diabetes mellitus. A general physical exam revealed widespread erythematous papules in an annular pattern on the trunk, characteristic of granuloma annulare. A series of tests were conducted, including autoimmune workup, all within normal limits. Histopathologic findings revealed features consistent with granuloma annulare. The patient was successfully treated with systemic corticosteroids for the uveitis and isotretinoin for the skin lesions. A close follow-up is recommended given the rare association of granuloma annulare and uveitis.

Characterizing Granuloma Annulare in 73 Pediatric Patients

Background

Granuloma annulare (GA) is a common, benign, idiopathic inflammatory dermatosis. Aside from case reports and small studies, there are limited data about the characteristics of GA in children.

Objective

This study aimed to better characterize the epidemiologic and clinical features, triggering factors, disease associations, and outcomes of GA in the pediatric population.

Methods

We conducted a retrospective study of 73 pediatric patients diagnosed with GA at the University of Rochester Medical Center over a 7-year period.

Results

The most common subtype was localized GA (71.2%, n = 52), followed by subcutaneous (also known as "deep GA"; 16.4%, n = 12) and generalized (12.3%, n = 9) subtypes. Over 90% of patients had idiopathic GA, with the remaining patients reporting viral infection or trauma as triggers. Half of the patients studied had comorbid conditions, most frequently atopic dermatitis (17.8%, n = 13), obesity (9.59%, n = 7), asthma (6.85%, n = 5), and allergic rhinitis (6.85%, n = 5). The median duration of the disease was 11.00 months (interquartile range (IQR) 15.75 months); generalized GA had the shortest duration (median 10.00 months, IQR 15.50 months), while subcutaneous GA had the longest duration (median 12.00 months and IQR 29.00 months). Although recurrence rates for subcutaneous and generalized GA were high at 45.5% and 33.3%, respectively, most patients achieved clearance or improvement with treatment.

Conclusion

Most cases of GA in our study were idiopathic, with no clear differences between GA subtypes and associated comorbidities. Topical steroids were the most prescribed treatment with mixed efficacy.

Clinicopathologic evaluation of granuloma annulare: Study of 136 Iranian cases, south of Iran

Background and Objectives

Granuloma annulare (GA) is a benign skin disorder with various histopathologic features that are rarely investigated in Iranian population. We performed this study to find out the clinical and histopathologic features of GA in our referral centre.

Methods

One hundred-thirty-six patients with biopsy-proven GA were reviewed. Clinical data and pathological features were recorded.

Results

One hundred-eight female patients and 28 male patients (Female/male ratio: 3.85) with mean age of 42.54 ± 21.2 years (range: 2-83 years) were recruited. Eighty-eight (64.7%) patients had interstitial infiltrative pattern and 48 (35.3%) patients had complete palisading granulomas. The infiltrate occupied both upper and lower dermis in most of the cases (67.7%). Significant mucin was detected more commonly in complete GA compared to interstitial GA (p = 0.019), but inflammation degree, eosinophils, plasma cells, and giant cells were not different between two subtypes of GA (p > 0.05). The significant inflammation contained more significant plasma cells (p = 0.006). The significantly more giant cells were detected in patients between 20 and 60 years of age (p = 0.015); but other factors were not different between age groups.

Conclusions

In our study, the prevalence of GA in women was significantly higher than in men. Interstitial GA was the more common histological subtype and the inflammation was less severe and the infiltrate was mostly pandermal in our cases. More severe inflammation contained more plasma cells, and more dense giant cells were seen in middle aged patients.

Generalized granuloma annulare in an infant clinically manifested as papules and atrophic macules: A case report

BACKGROUND

Granuloma annulare (GA) has diverse clinical manifestations including papules, plaques, and nodules on the extremities that are skin-colored, pink, or purple. Approximately 15% of all GA cases are considered generalized GA.

CASE SUMMARY

Herein, we describe the case of a pediatric patient who initially presented with papules and later developed generalized atrophic macules. Upon examination, two different morphologic lesions were histopathologically confirmed: Epithelioid nodular GA and scattered histiocytic infiltrative GA. This patient exhibited rare clinical manifestations that differed throughout the course of the disease. The varying histopathological types and clinical manifestations of GA may be linked to the different stages of the disease.

CONCLUSION

This rare case demonstrates the different histopathological features of different stages and clinical manifestations of granuloma annulare in an infant.

Molecularly Targeted Therapies for Inflammatory Cutaneous Granulomatous Disorders: A Review of the Evidence and Implications for Understanding Disease Pathogenesis

Inflammatory cutaneous granulomatous diseases, including granuloma annulare, cutaneous sarcoidosis, and necrobiosis lipoidica, are distinct diseases unified by the hallmark of macrophage accumulation and activation in the skin. There are currently no Food and Drug Administration-approved therapies for these conditions except prednisone and repository corticotropin injection for pulmonary sarcoidosis. Treatment of these diseases has generally been guided by low-quality evidence and may involve broadly immunomodulatory medications. Development of new treatments has in part been limited by an incomplete understanding of disease pathogenesis. Recently, there has been substantial progress in better understanding the molecular pathogenesis of these disorders, opening the door for therapeutic innovation. Likewise, reported outcomes of treatment with immunologically targeted therapies may offer insights into disease pathogenesis. In this systematic review, we summarize progress in deciphering the pathomechanisms of these disorders and discuss this in the context of emerging evidence on the use of molecularly targeted therapies in treatment of these diseases.

Elastic fiber degradation in the development of pediatric granuloma annulare: Report of 39 cases

BACKGROUND

Granuloma annulare (GA) has diverse clinical manifestations, multiple subtypes, and unknown etiology and pathogenesis. Existing studies regarding GA in children are scarce.

AIM

To examine the correlation between clinical manifestation and histopathology of pediatric GA.

METHODS

A total of 39 patients under 18 years of age with both a clinical and pathological diagnosis of GA at Kunming Children's Hospital from 2017 to 2022 were retrieved. Their medical records were consulted, and clinical data of the children were recorded and summarized, including gender, age, disease site, etc. Existing wax blocks of skin lesion specimens of children and pathological films were retrieved for further study and relevant histology, including hematoxylin-eosin, Alcian blue, elastic fiber (Victoria blue-Lichon red method), and antacid staining. Finally, the children’s clinical manifestations, histopathological results, and special staining characteristics were analyzed.

RESULTS

The clinical manifestations of granuloma annulare in children were diverse: 11 cases presented with a single lesion, 25 with multiple lesions, and 3 with generalized lesions. The pathological typing comprised histiocytic infiltration, palisading granuloma, epithelioid nodular, and mixed types in 4, 11, 9, and 15 cases, respectively. Thirty-nine cases were negative for antacid staining. The positive rate of Alcian blue staining was 92.3%, and that of elastic fiber staining was 100%. The degree of elastic fiber dissolution and granuloma annulare histopathological typing were positively correlated (r = 0.432, P < 0.05). No correlation was found between clinical presentation and histopathological typing of the granuloma annulare in children. In the pathological diagnosis of granuloma annulare, the positive elastic fiber staining rate was higher than that of Alcian blue staining. A correlation was found between elastic fiber dissolution degree and histopathological staging. However, the differences in pathological staging may have been related to the pathological manifestation of granuloma annulare at different periods.

CONCLUSION

Elastic fiber degradation may be a critical step in the pathogenesis of pediatric granuloma annulare. This is also one of the first studies focused on granuloma annulare in children.

Histopathologic Aspects of Malignancy-Associated Granuloma Annulare: A Single Institution Experience

Granuloma annulare (GA) is a benign, self-limiting granulomatous inflammatory disease that exhibits different histologic patterns. Infrequently, granuloma annulare can be associated with malignancy, the so-called malignancy-associated granuloma annulare (MGA). In this study, we aimed to compare the clinical and histopathological differences between GA and MGA. We retrospectively reviewed patient charts and identified 35 patients diagnosed with GA and concurrent hematological or solid organ malignancies as a case group. Additionally, we identified 33 patients without any known solid organ or hematological malignancy as a control group. MGA is commonly seen in the seventh decade of life, while GA affects the younger population. MGA is most commonly presented in the extremities of the body. The most common malignancy associated with MGA was chronic lymphocytic leukemia. Prostate cancer was the most common type of solid organ malignancy that was associated with MGA. The most common histopathological pattern seen in MGA was interstitial, comprising half of the cases. Multinucleated giant cells were present in half of the MGA cases and in most of the control group. In the literature, there are no established features that distinguish MGA from GA. Although MGA and GA have overlapping features, in our series, we found that the interstitial pattern was more common in MGA, while the necrobiotic pattern was more common in GA.

Generalized Granuloma Annulare Associated with Sjogren's Syndrome: A Case Report

Granuloma annulare (GA) is an uncommon disease in dermatology. Here, we report a case of generalized GA combined with Sjogren's syndrome (SS) in a 65-year-old woman. To our knowledge, generalized GA combined with SS has not been reported before.

Granuloma annulare after SARS-CoV-2 vaccination: A case report and a literature review

INTRODUCTION

During the Cov-19 pandemic, many studies reported a broad spectrum of cutaneous reactions presenting as erythematous rashes or pernio-like, urticaria-like or vesicular/bullous patterns associated with Cov-19-infection and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination.

METHODS

The authors documented the clinical and histopathological features of an unexpected case of granuloma annulare (GA) arising a few days after the SARS-CoV-2 vaccination and reviewed all GAs reported in the literature following the SARS-CoV-2 vaccination and Cov-19-infection.

CASE REPORT

A 69-year-old woman developed a single reddish lesion on the left deltoid region, where the SARS-CoV-2 vaccine seven days earlier was injected. The clinicians performed a punch skin biopsy, and histology revealed an interstitial GA.

CONCLUSIONS

Clinicians should be aware of the potential, though rare, GA occurrence as a possible adverse event after the SARS-CoV-2 vaccination. This additional case, like what happens after the administration of other vaccines, supports the idea that GA may result from the immune system activation following the vaccination. However, notwithstanding, they should encourage their patients to obtain immunization to assist the public health systems in overcoming the COVID-19 pandemic.

Patient perspectives on the lived experience of granuloma annulare

Granuloma annulare is a relatively common inflammatory skin disease, yet patient-centered impacts of GA have not been thoroughly investigated, including the potential psychosocial and symptomatic burden, patients’ motivation for treatment, and patients’ perception of usefulness of commonly used medications. We conducted a survey of greater than 900 patients with GA and found an unexpectedly significant impact of GA on the quality of life, a generally poor reported response to commonly used therapies, and that symptoms such as itch and discomfort are not uncommon and may be the primary motivator for seeking treatment. More effective therapies and an understanding of their effect on quality of life is needed.

The association of anxiety with granuloma annulare: a case-control study of the National Institutes of Health 'All of Us' research programme

Dear Editor, Granuloma annulare (GA) is an inflammatory skin disease that has been associated with diabetes, dyslipidaemia, hypothyroidism and autoimmune disorders.1,2 The annualized incidence and prevalence of GA in the USA are approximately 0.04% and 0.06%, respectively (with a female predominance).3 GA is clinically classified as localized (75% of cases), generalized or subcutaneous.4 There is a body of evidence supporting an association between several inflammatory dermatoses, such as psoriasis, and mental health conditions.5 Improvement of depression and anxiety following treatment of certain inflammatory dermatoses has also been described.5 It has been postulated that this association may, in part, relate to proinflammatory cytokines, which have been proposed to mechanistically connect inflammatory dermatoses and mental health conditions.6 A recent nested case-control study demonstrated a significant association of GA with depression, insomnia, opioid dependence and post-traumatic stress disorder.7 This study aims to investigate whether an association exists between GA and anxiety.

A Unique Case of Squamous Cell Carcinoma Presenting Within a Lesion of Granuloma Annulare

Granuloma annulare (GA) is a common benign granulomatous inflammatory disorder of the dermis or subcutis with classic morphologic and histologic presentation. Common clinical subtypes of granuloma annulare include localized, generalized, subcutaneous, perforating, and patch types. A biopsy is critical in cases of granuloma annulare with atypical features. We present a case of a 58-year-old male who presented with an annular scaly erythematous plaque on the right dorsal hand. Shave biopsy demonstrated irregular nests of mildly atypical squamous epithelium present within the superficial dermis, with abundant histiocytes and multinucleated giant cells arranged in palisades peripherally. These findings were consistent with invasive well-differentiated squamous cell carcinoma (SCC) with surrounding granuloma annulare. This case highlights a unique presentation in which clinicopathologic correlation is critical prior to arriving at a correct diagnosis.

Granuloma Annulare: An Updated Review of Epidemiology, Pathogenesis, and Treatment Options

Granuloma annulare (GA) is an inflammatory granulomatous skin disease that can be localized (localized GA) or disseminated (generalized GA), with patch, perforating, and subcutaneous subtypes being less common variants of this benign condition. Recently, new research has emerged that further elucidates GA epidemiology and etiopathogenesis; importantly, new therapeutic options for GA have also been described, although there remains a paucity of randomized controlled studies. In this review, we summarize recent updates on GA epidemiology and etiopathogenesis and offer an updated review of the therapeutic options for GA currently reported in the literature. We hope that the current review galvanizes randomized controlled studies that will in turn help lead to the recommendation of evidence-based treatments for GA.

Association of Granuloma Annulare With Type 2 Diabetes, Hyperlipidemia, Autoimmune Disorders, and Hematologic Malignant Neoplasms

IMPORTANCE

Although granuloma annulare (GA) has been associated with several other conditions, these studies have been limited by single-center designs and small sample sizes.

OBJECTIVE

To evaluate whether there is an association between GA and type 2 diabetes, hyperlipidemia, autoimmune conditions, and hematologic malignant neoplasms, using a large population-based cohort study.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study conducted between January 1, 2016, and June 30, 2019, used deidentified data from the US Optum Clinformatics Data Mart Database. A total of 5137 patients with GA were matched by age and sex with up to 10 randomly selected controls (n = 51 169) with a diagnosis of a nevus or seborrheic keratosis.

MAIN OUTCOMES AND MEASURES

Logistic regression was used to evaluate for potential associations between GA and diabetes, hyperlipidemia, autoimmune conditions, and hematologic malignant neoplasms. All analyses were adjusted for race/ethnicity, income, and educational level.

RESULTS

This study included 5137 individuals with GA (3760 women [73.2%]; mean [SD] age, 57.7 [19.0] years) and 51 169 controls (37 456 women [73.2%]; mean [SD] age, 57.7 [19.0] years). Those with GA were more likely than controls to have baseline diabetes (1086 [21.1%] vs 6780 [13.3%]; adjusted odds ratio [aOR], 1.67; 95% CI, 1.55-1.80), hyperlipidemia (1669 [32.5%] vs 14 553 [28.4%]; aOR, 1.15; 95% CI, 1.08-1.23), hypothyroidism (727 [14.2%] vs 5780 [11.3%]; aOR, 1.24; 95% CI, 1.15-1.36), and rheumatoid arthritis (62 [1.2%] vs 441 [0.9%]; aOR, 1.34; 95% CI, 1.02-1.75). Those with GA were more likely to have incident diabetes (144 [2.8%] vs 1061 [2.1%]; aOR, 1.31; 95% CI, 1.10-1.57), hypothyroidism (41 [0.8%] vs 252 [0.5%]; aOR, 1.59; 95% CI, 1.14-2.22), systemic lupus erythematosus (21 [0.4%] vs 65 [0.1%]; aOR, 3.06; 95% CI, 1.86-5.01), and rheumatoid arthritis (26 [0.5%] vs 122 [0.2%]; aOR, 2.05; 95% CI, 1.34-3.13). There was no association between GA and an increased risk of hematologic malignant neoplasms.

CONCLUSIONS AND RELEVANCE

This population-based cohort study identified associations between GA and baseline diabetes and hyperlipidemia as well as between GA and both baseline and incident autoimmune conditions. These findings suggest that diabetes and hyperlipidemia may be risk factors for the development of GA and that autoimmunity may be an important factor in the pathogenesis of GA.