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Lee EC, Steffen CA, Carroz ME, Lee CL, Lee LA. Granuloma annulare and possible relation to purified protein derivative administration: a case report. J Med Case Rep 2024; 18:299. [PMID: 38902812 PMCID: PMC11188238 DOI: 10.1186/s13256-024-04598-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 05/14/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Granuloma annulare is a noninfectious inflammatory granulomatous skin disease characterized by an erythematous or skin colored annulare plaque. The diagnosis of granuloma annulare may be challenging owing to its diverse morphology. In such cases, a correlation between the clinical findings and histologic findings are necessary. CASE PRESENTATION We report a case of granuloma annulare after purified protein derivative administration. A 56-year-old Caucasian female patient complained of mildly pruritic rashes which started on both arms and lower extremities, and eventually spread to both thighs, the left popliteal region, left upper back, and the right abdominal area. About 6 weeks prior to the eruption of the rashes, the patient had been given a purified protein derivative tuberculin skin test. Biopsy specimens revealed dermal histiocytes palisading around areas of mucin and degenerated collagen, confirming granuloma annulare. After treatment with 0.1% topical triamcinolone acetanide and 500 mg oral metronidazole, the patient's lesions resolved. DISCUSSION Relatively little is known about granuloma annulare's exact etiology. Granuloma annulare has four variations presenting as either localized, generalized, subcutaneous, or perforating and patch granuloma annulare. The clinical prognosis for granuloma annulare varies according to clinical subtypes. Proposed causal mechanisms of subcutaneous granuloma annulare include physical trauma, infections, immunizations, insect bites, diabetes mellitus, and alterations in the cell-mediated immune responses. The disease likely has an inflammatory component. Clinically, granuloma annulare may be confused with many other skin diseases. CONCLUSION This case of subcutaneous granuloma annulare was reported since it is a rare dermatologic pathological condition that can be confused with other skin rash disorders. Although it is a benign self-limited disease, definitive diagnosis is important to rule out other pathologies with similar clinical appearances, such as cancer or human immunodeficiency virus (HIV) infection. Diagnostic confirmation is best made through skin biopsy.
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Affiliation(s)
- Ernest C Lee
- Phoenix VA Health Care System, Phoenix, USA.
- The University of Arizona College of Medicine, Phoenix, USA.
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2
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Calik J, Zawada T, Sauer N, Bove T. High Intensity Focused Ultrasound (20 MHz) and Cryotherapy as Therapeutic Options for Granuloma Annulare and Other Inflammatory Skin Conditions. Dermatol Ther (Heidelb) 2024; 14:1189-1210. [PMID: 38703308 PMCID: PMC11116313 DOI: 10.1007/s13555-024-01163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/08/2024] [Indexed: 05/06/2024] Open
Abstract
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.
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Affiliation(s)
- Jacek Calik
- Old Town Clinic, Wszystkich Świętych 2a, 50-127, Wrocław, Poland
- Department of Clinical Oncology, Wroclaw Medical University, 50-556, Wrocław, Poland
| | - Tomasz Zawada
- TOOsonix A/S, Agern Allé 1, 2970, Hoersholm, Denmark.
| | - Natalia Sauer
- Old Town Clinic, Wszystkich Świętych 2a, 50-127, Wrocław, Poland
- Faculty of Pharmacy, Wroclaw Medical University, 50-556, Wrocław, Poland
| | - Torsten Bove
- TOOsonix A/S, Agern Allé 1, 2970, Hoersholm, Denmark
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Horoub YA, Walker K. Improvement of generalized granuloma annulare with adalimumab: A case report. SAGE Open Med Case Rep 2024; 12:2050313X241231427. [PMID: 38371951 PMCID: PMC10874154 DOI: 10.1177/2050313x241231427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/11/2023] [Indexed: 02/20/2024] Open
Abstract
Granuloma annulare is a benign, inflammatory condition of unknown etiology, characterized by erythematous annular plaques, frequently on distal extremities. Generalized granuloma annulare can be difficult to treat, with varying success in therapeutic approaches. We present the case of a 59-year-old female with refractory generalized granuloma annulare successfully managed with adalimumab, requiring ongoing 40 mg q2weekly treatment for 2 years. While there are a handful of published case reports/series suggesting that adalimumab can be used to treat generalized granuloma annulare, dosing regimens and the need for long-term use remain inconsistent. This case adds further evidence for considering adalimumab as a sustained therapeutic option for recalcitrant generalized granuloma annulare. The patient responded to adalimumab, a tumor necrosis factor-alpha antagonist, administered biweekly for a year, then switched to weekly intervals. Most granuloma annulare lesions improved within 2 months and continued to improve throughout the treatment. Adalimumab may be proposed as a therapeutic treatment for recalcitrant forms of generalized granuloma annulare.
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Affiliation(s)
- Yara Al Horoub
- University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Kirsten Walker
- University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
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Kim D, Kim YC. Successful Treatment of Granuloma Annulare Using Ablative Fractional Carbon Dioxide Laser-Assisted Photodynamic Therapy. Ann Dermatol 2023; 35:S355-S356. [PMID: 38061742 PMCID: PMC10727882 DOI: 10.5021/ad.21.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/20/2021] [Accepted: 01/24/2022] [Indexed: 12/20/2023] Open
Affiliation(s)
- Dongchan Kim
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea
| | - You Chan Kim
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea.
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5
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Calado R, Figueiredo C, Cardoso JC, Oliveira HS. Generalized Papular Granuloma Annulare Presenting With Pseudoxanthoma Elasticum-Like Lesions. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:T839-T840. [PMID: 37506833 DOI: 10.1016/j.ad.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/25/2022] [Indexed: 07/30/2023] Open
Affiliation(s)
- R Calado
- Servicio de Dermatología del Hospital Universitario de Coimbra, Coimbra, Portugal.
| | - C Figueiredo
- Servicio de Dermatología del Hospital Universitario de Coimbra, Coimbra, Portugal
| | - J C Cardoso
- Servicio de Dermatología del Hospital Universitario de Coimbra, Coimbra, Portugal
| | - H S Oliveira
- Servicio de Dermatología del Hospital Universitario de Coimbra, Coimbra, Portugal
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Calado R, Figueiredo C, Cardoso JC, Oliveira HS. Generalized Papular Granuloma Annulare Presenting With Pseudoxanthoma Elasticum-Like Lesions. ACTAS DERMO-SIFILIOGRAFICAS 2023; 114:839-840. [PMID: 36740175 DOI: 10.1016/j.ad.2022.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 04/18/2022] [Accepted: 05/25/2022] [Indexed: 02/05/2023] Open
Affiliation(s)
- R Calado
- Coimbra Hospital University Centre, Department of Dermato-venereology, Coimbra, Portugal.
| | - C Figueiredo
- Coimbra Hospital University Centre, Department of Dermato-venereology, Coimbra, Portugal
| | - J C Cardoso
- Coimbra Hospital University Centre, Department of Dermato-venereology, Coimbra, Portugal
| | - H S Oliveira
- Coimbra Hospital University Centre, Department of Dermato-venereology, Coimbra, Portugal
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Gurioli C, Misciali C, Robuffo S, Baraldi C, Boling LB, Piraccini BM. Papular Granuloma Annulare Mimicking Viral Warts. Dermatol Pract Concept 2023; 13:dpc.1304a207. [PMID: 37992393 PMCID: PMC10656127 DOI: 10.5826/dpc.1304a207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 11/24/2023] Open
Affiliation(s)
- Carlotta Gurioli
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy
| | - Cosimo Misciali
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy
| | - Silvia Robuffo
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy
| | - Carlotta Baraldi
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy
| | - Lindsay Brooke Boling
- Allergy and Clinical Immunology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Bianca Maria Piraccini
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy
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8
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Choe CS, Hao LM, Mancini AJ. Taking the "Worm" out of Ringworm: A Different Annular Rash in Children. J Pediatr 2023; 260:113497. [PMID: 37211207 DOI: 10.1016/j.jpeds.2023.113497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/14/2023] [Indexed: 05/23/2023]
Affiliation(s)
- Caleb S Choe
- Division of Pediatric Dermatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lauren M Hao
- Division of Pediatric Dermatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anthony J Mancini
- Division of Pediatric Dermatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics and Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL
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9
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Navea OV, Navea MB, De la Fuente R. Concomitant Subtypes of Granuloma Annulare in a 66-Year-Old Female: A Case Report. Cureus 2023; 15:e46026. [PMID: 37900443 PMCID: PMC10602710 DOI: 10.7759/cureus.46026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Granuloma annulare (GA) is a benign, self-limited inflammatory skin condition with an unknown etiology. Although it usually presents with characteristic clinical features, a biopsy may be necessary in atypical cases to differentiate it from other granulomatous diseases. We describe a case of a 66-year-old female with two concomitant subtypes of GA, presenting with distinct clinical features but exhibiting similar histopathological findings. The patient had extensive, pruritic erythematous-violaceous lesions on her lower abdomen, buttocks, and proximal thighs, which had been progressing over the course of one year. Biopsies from the abdominal and thigh lesions showed typical histopathological features of GA, with mucin deposition, histiocytic infiltrate, and granulomatous formations. Treatment with oral antihistamines and medium-potency topical corticosteroids effectively controlled the itching but did not alter the lesion's appearance. Five months later, the patient developed new, pruritic, skin-colored, confluent papules on the internal face of her left arm, and a subsequent biopsy confirmed annular GA. Although the patient did not follow the prescribed dapsone treatment, the lesions spontaneously regressed within a year. This case emphasizes the importance of recognizing less common presentations of GA, which can mimic other, more concerning conditions. While various therapeutic options have been explored, none guarantee complete remission; however, GA typically resolves on its own over time. A better understanding of the disease's pathogenesis and the development of targeted treatments are warranted to improve management strategies for GA.
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Affiliation(s)
- Oscar V Navea
- General Practice, Universidad de los Andes, Santiago, CHL
| | - Maria B Navea
- General Practice, Universidad de Chile, Santiago, CHL
| | - Raul De la Fuente
- Dermatology, Hospital Clínico de la Universidad de Chile, Santiago, CHL
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Paganini C, Talamonti M, Campione E, Bianchi L, Galluzzo M. Letter in response to the case report: "Recalcitrant generalized granuloma annulare treated successfully with dupilumab". JAAD Case Rep 2023; 39:152-154. [PMID: 37693925 PMCID: PMC10491842 DOI: 10.1016/j.jdcr.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Affiliation(s)
- Claudia Paganini
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Marina Talamonti
- Dermatology Unit, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Elena Campione
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Dermatology Unit, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Luca Bianchi
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Dermatology Unit, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Marco Galluzzo
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Dermatology Unit, Fondazione Policlinico Tor Vergata, Rome, Italy
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11
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Connor BW, Smith SE, Kalus A. Exploring Immune Therapies in a Twin Case of Latent Autoimmune Diabetes in Adults and Generalized Granuloma Annulare. Clin Diabetes 2023; 41:583-586. [PMID: 37849513 PMCID: PMC10577501 DOI: 10.2337/cd22-0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Affiliation(s)
- Brian W. Connor
- University of Washington School of Medicine, Seattle, WA
- Department of Internal Medicine, Division of Dermatology, University of Washington, Seattle, WA
| | | | - Andrea Kalus
- University of Washington School of Medicine, Seattle, WA
- Department of Internal Medicine, Division of Dermatology, University of Washington, Seattle, WA
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12
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Kluger N. Annular Erythemas and Purpuras. Life (Basel) 2023; 13:1245. [PMID: 37374026 DOI: 10.3390/life13061245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/13/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Annular dermatoses are a heterogeneous and extremely diverse group of skin diseases, which share in common annular, ring-like patterns with centrifugal spreading. Numerous skin diseases can sometimes display annular lesions, but some specific skin conditions are originally annular. We take the opportunity to review here mainly the causes of primary annular erythemas and their differential diagnoses, but also the rare causes of annular purpuras.
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Affiliation(s)
- Nicolas Kluger
- Department of Dermatology, Allergology and Venereology, Helsinki University Hospital & University of Helsinki, 00250 Helsinki, Finland
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13
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Uzuncakmak TK, Durdu M, Karadag AS. Granulomatous annular diseases. Clin Dermatol 2023; 41:355-367. [PMID: 37467899 DOI: 10.1016/j.clindermatol.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Granulomatous skin disorders comprise a large group of diseases that are typically characterized by granuloma formation both in the skin and in many other tissues. Cutaneous lesions are usually seen as erythematous papules and plaques that may occasionally be arranged in an annular, ringlike configuration. The etiopathogenesis is unclear in most cases, and granuloma formation may be associated with various systemic, infectious, and metabolic disorders, foreign bodies, environmental antigens, or malignancies. Treatment options are dependent on the etiology, extent, and severity of the lesions. This review includes the clinical, histopathologic, and dermatoscopy findings, differentials, and treatment options for noninfectious granulomatous annular skin disorders.
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Affiliation(s)
| | - Murat Durdu
- Department of Dermatology, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Application and Research Center, Adana, Turkey
| | - Ayse Serap Karadag
- Department of Dermatology, Istanbul Arel University Medical Faculty, Istanbul, Turkey.
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14
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Leson S, Braun SA. Testen Sie Ihr Fachwissen. AKTUELLE DERMATOLOGIE 2023. [DOI: 10.1055/a-1968-7387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Affiliation(s)
- Sonja Leson
- Klinik für Hautkrankheiten, Universitätsklinikum Münster, Münster
| | - Stephan A. Braun
- Klinik für Hautkrankheiten, Universitätsklinikum Münster, Münster
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15
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Park L, Green C, Arutyunyan S, Vasile G, Buckley C, Weiss E. Effects of canary seed on two patients with disseminated granuloma annulare. Dermatol Reports 2022. [DOI: 10.4081/dr.2023.9614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Treatment of disseminated granuloma annulare (GA) can be challenging and there is no gold standard for treatment. We observed two cases of generalized GA that had been resistant to other treaments successfully treated with canary seed milk. Canary seed milk has antioxidant (contains vitamin E), anti-diabetic (DPP-4 inhibition), and anti-hypertensive (ACE inhibition) properties. Therefore, dermatologists can consider alpiste milk as a sole or supplemental treatment for patients with GA with or without comorbidities such as diabetes and hypertension, in GA patients who prefer alternative therapy or failed other treatments.
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16
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Zhang LW, Jiang CH, Wang WJ, He L, Chen T. Auricular granuloma annulare. Indian J Dermatol Venereol Leprol 2022; 88:800-803. [PMID: 36331829 DOI: 10.25259/ijdvl_197_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/01/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Li-Wen Zhang
- Department of Dermatovenereology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Cun-Huo Jiang
- Department of Dermatovenereology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Wen-Ju Wang
- Department of Dermatovenereology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Lin He
- Department of Pathology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Tao Chen
- Department of Dermatovenereology, Chengdu Second People's Hospital, Chengdu, Sichuan, China
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Generalized perforating granuloma annulare appearing during pregnancy. Int J Womens Dermatol 2022; 8:e041. [PMID: 35983560 PMCID: PMC9377681 DOI: 10.1097/jw9.0000000000000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 07/14/2022] [Indexed: 11/26/2022] Open
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Zabel ML, Evans T, Sutton AV, Stephany M. A Unique Case of Squamous Cell Carcinoma Presenting Within a Lesion of Granuloma Annulare. Cureus 2022; 14:e27845. [PMID: 36110441 PMCID: PMC9462656 DOI: 10.7759/cureus.27845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Liu W, Ma DL. Generalised annular plaques on the trunk. BMJ 2022; 378:e067430. [PMID: 35858699 DOI: 10.1136/bmj-2021-067430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Wei Liu
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Skin and Immune Diseases, Beijing, 100730, China
| | - Dong-Lai Ma
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Skin and Immune Diseases, Beijing, 100730, China
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Brandes GIG, Peixoto-Barbosa R, Meski APG, Giuffrida FMA, Reis AF. Granuloma annulare and necrobiosis lipoidica in a patient with HNF1A-MODY. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:420-424. [PMID: 35551682 PMCID: PMC9832856 DOI: 10.20945/2359-3997000000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/22/2021] [Indexed: 11/23/2022]
Abstract
Maturity-onset diabetes of the young (MODY) is a heterogeneous group of monogenic forms of diabetes mellitus with distinct clinical features. Clinical dermatological phenotypes in MODY patients are very rare in literature. This report describes a patient with HNF1A-MODY presenting with necrobiosis lipoidica (NL) and granuloma annulare (GA). A 39-year-old asymptomatic woman, with atypical diabetes diagnosed at age 17, has a confirmed HNF1A mutation on exon 2 (c.392G>A, p.R131Q), classified as Pathogenic by the ACMG guidelines. She has reasonable metabolic control using oral anti-diabetic medications and has no chronic diabetic complications. Clinical and histologic diagnoses of both NL and GA were made. We discuss these conditions and their association with MODY.
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Affiliation(s)
| | - Renata Peixoto-Barbosa
- Disciplina de Endocrinologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
- Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Salvador, BA, Brasil
| | - Ana Paula Gomes Meski
- Departamento de Dermatologia, Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo, SP, Brasil
| | - Fernando M A Giuffrida
- Disciplina de Endocrinologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil,
- Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Salvador, BA, Brasil
- Fernando M. A. Giuffrida is joint senior author
| | - André F Reis
- Disciplina de Endocrinologia, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
- André F. Reis is joint senior author
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Granuloma Annulare: An Updated Review of Epidemiology, Pathogenesis, and Treatment Options. Am J Clin Dermatol 2022; 23:37-50. [PMID: 34495491 PMCID: PMC8423598 DOI: 10.1007/s40257-021-00636-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 12/20/2022]
Abstract
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.
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22
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Kök GF, Türsen Ü. The Immunogenetics of Granulomatous Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1367:349-368. [DOI: 10.1007/978-3-030-92616-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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PROVVIDENZIALE L, PELLEGRINO M, MANCINI V, FIMIANI M. Treatment of resistant granuloma annulare with rifampin, norfloxacin, and minocycline combination therapy. Ital J Dermatol Venerol 2022; 156:28-29. [DOI: 10.23736/s2784-8671.19.06270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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24
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Dopytalska K, Gabzdyl N, Szczerba M, Szymańska E, Walecka I. Is biologic therapy the future of granuloma annulare treatment? Dermatol Ther 2021; 35:e15188. [PMID: 34730269 DOI: 10.1111/dth.15188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/23/2021] [Indexed: 11/28/2022]
Abstract
Granuloma annulare (GA) is a benign inflammatory skin disease that presents with erythematous papules and annular plaques. The pathogenesis of GA remains unknown and may potentially involve type 1 T helper cell (Th1)-mediated delayed-type hypersensitivity reaction. GA is associated with many conditions such as malignancy, trauma, thyroid disease, diabetes mellitus, and viral infection. The role of biological treatment is under investigation. In this article, we present a case of GA development following systemic treatment of psoriatic arthritis in a 59-year-old patient; golimumab therapy resulted in the successful treatment of both psoriatic arthritis and GA. This is the first case report describing GA therapy using golimumab.
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Affiliation(s)
- Klaudia Dopytalska
- Department of Dermatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Natalia Gabzdyl
- Department of Dermatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Szczerba
- Department of Dermatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Elżbieta Szymańska
- Department of Dermatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Irena Walecka
- Department of Dermatology, Centre of Postgraduate Medical Education, Warsaw, Poland
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25
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Holland TE, Holland LW, Miller AC, Freeman WE. Treatment of Granuloma Annulare With Pentoxifylline and Oral Vitamin E: A Case Series. Cureus 2021; 13:e18151. [PMID: 34703689 PMCID: PMC8530181 DOI: 10.7759/cureus.18151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/09/2022] Open
Abstract
Granuloma annulare (GA) is a difficult-to-treat granulomatous skin disorder characterized by multiple annular, raised, and erythematous lesions. While numerous therapies have been proposed, there is currently no clear gold standard of treatment. We present a series of five patients with biopsy-proven generalized GA who were treated with pentoxifylline and oral vitamin E. Each patient in this series had at least a one-year history of GA refractory to other treatments. After three months of treatment, four of the five patients demonstrated objective improvement in their lesions through before and after clinical photographs. No patients suffered any adverse events on this treatment regimen. As our series has demonstrated modest benefits in concurrence with previously published studies, we recommend combination therapy with pentoxifylline and vitamin E as a strong contender for first- or second-line treatment for generalized GA. Pentoxifylline and vitamin E are advantageous for their tolerability, cost-effectiveness, minimal drug interactions, and convenience.
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Affiliation(s)
- Timothy E Holland
- United States Air Force (USAF) Medical Service, United States Air Force, Falls Church, USA
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26
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Lam M, Hilal MA. Generalized Granuloma Annulare: A Retrospective Study From Southern Ontario, Canada. J Cutan Med Surg 2021; 26:208-209. [PMID: 34587816 DOI: 10.1177/12034754211048679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Megan Lam
- 12362 Michael G. DeGroote School of Medicine, Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohannad Abu Hilal
- 3710 Division of Dermatology, McMaster University, Hamilton, Ontario, Canada
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27
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McPhie ML, Swales WC, Gooderham MJ. Improvement of granulomatous skin conditions with tofacitinib in three patients: A case report. SAGE Open Med Case Rep 2021; 9:2050313X211039477. [PMID: 34422275 PMCID: PMC8375329 DOI: 10.1177/2050313x211039477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Granulomatous skin conditions are poorly understood inflammatory skin diseases consisting predominantly of macrophages. Granuloma annulare (GA) is the most common granulomatous skin disease and the generalized variant is particularly difficult to treat due to the prolonged course and lack of efficacious treatment options. Necrobiosis lipoidica (NL) is another granulomatous disorder of uncertain etiology. There is a growing body of evidence for the use of Janus kinase (JAK) inhibitors in the management of inflammatory skin diseases. In our report, we describe three patients with recalcitrant granulomatous disease including NL and generalized GA who responded favourably to treatment with the JAK inhibitor tofacitinib. JAK inhibitors may be a beneficial therapeutic option for patients with granulomatous skin diseases that are unresponsive to conventional therapies. Further research is required to determine the long-term efficacy and safety of JAK inhibitors in treating granulomatous skin conditions.
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Affiliation(s)
| | - William C Swales
- SKiN Centre for Dermatology, Peterborough, ON, Canada
- Probity Medical Research, Waterloo, ON, Canada
| | - Melinda J Gooderham
- Queen’s University, Kingston, ON, Canada
- SKiN Centre for Dermatology, Peterborough, ON, Canada
- Probity Medical Research, Waterloo, ON, Canada
- Melinda J Gooderham, SKiN Centre for Dermatology, 775 Monaghan Road, Peterborough, ON K9J 5K2, Canada.
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28
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Hrin ML, Bowers NL, Feldman SR, Huang WW. Methotrexate for generalized granuloma annulare: A 60% response rate in a retrospective case series of 15 patients. J Am Acad Dermatol 2021; 87:201-203. [PMID: 34333082 DOI: 10.1016/j.jaad.2021.07.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Matthew L Hrin
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Nathan L Bowers
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven R Feldman
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Dermatology, University of Southern Denmark, Odense, Denmark
| | - William W Huang
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Hrin ML, Feldman SR, Huang WW. Hydroxychloroquine for generalized granuloma annulare: 35% response rate in a retrospective case series of 26 patients. J Am Acad Dermatol 2021; 87:144-147. [PMID: 34216720 DOI: 10.1016/j.jaad.2021.06.867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/01/2021] [Accepted: 06/19/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Matthew L Hrin
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Steven R Feldman
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Dermatology, University of Southern Denmark, Odense, Denmark
| | - William W Huang
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
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30
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Hansel K, Biondi F, Bianchi L, Tramontana M, Marietti R, Stingeni L. Generalized granuloma annulare successfully treated with apremilast: report of two cases and literature review. Clin Exp Dermatol 2021; 46:1603-1606. [PMID: 34184292 DOI: 10.1111/ced.14806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Affiliation(s)
- K Hansel
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - F Biondi
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - L Bianchi
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - M Tramontana
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - R Marietti
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - L Stingeni
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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31
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Abstract
Granuloma annulare (GA) is a common inflammatory skin condition that manifests as annular skin colored to erythematous papules and plaques. Disseminated GA is a subtype of GA that presents with diffuse cutaneous involvement. While topical and intralesional corticosteroids and phototherapy have been used as therapies for GA, there is no consensus on the best course of treatment for GA. Apremilast is a phosphodiesterase 4 (PDE4) inhibitor that has been Food and Drug Administration (FDA) approved for psoriasis, psoriatic arthritis, and oral ulcers associated with Behcet’s disease; apremilast has also shown promise off-label for other inflammatory skin conditions. Here, we present the case of a woman in whom apremilast use led to an almost complete resolution of her disseminated GA. Our patient tolerated apremilast well and reported no side effects. We also review the literature on the use of apremilast in other patients with GA.
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Affiliation(s)
- Tejas P Joshi
- Dermatology, Baylor College of Medicine, Houston, USA
| | - Jaime Tschen
- Dermatology, St. Joseph Dermatopathology, Houston, USA
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32
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Manoharan P, Kaliaperumal K. Salt and skin. Int J Dermatol 2021; 61:291-298. [PMID: 33890287 DOI: 10.1111/ijd.15588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/04/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
The introduction of salt as a therapeutic agent in dermatological disorders has been in use since ancient times. This ubiquitous agent is the most underrated substance after the advent of modern medicine. Though a commonly used agent in both traditional and modern medicine, it is important to understand its relationship to the skin to further enhance the comprehensive benefit. The complex history of the evolution of medicine and its skewed distribution among the countries of the world led to inclusion of locally available and economical agents into therapeutics as it becomes almost an inevitable need. Moreover, an inadequate knowledge about the harmful effects of chronic salt exposure led salt to have a unique role in occupational dermatoses. There is no adequate literature on both detrimental and therapeutic effects of salt and its relation to skin. Hence, a genuine attempt was made to summarize the known and the lesser known facts of this particular common seasoning agent.
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Affiliation(s)
- Prarthana Manoharan
- Department of Dermatology, Venereology & Leprosy, Sri Manakula Vinayagar Medical College & Hospital, Puducherry, India
| | - Karthikeyan Kaliaperumal
- Department of Dermatology, Venereology & Leprosy, Sri Manakula Vinayagar Medical College & Hospital, Puducherry, India
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33
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Hrin ML, Bashyam AM, Feldman SR, Huang WW. Oral dapsone for the treatment of generalized granuloma annulare: A retrospective case series. J Am Acad Dermatol 2021; 86:911-914. [PMID: 33753254 DOI: 10.1016/j.jaad.2021.03.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Matthew L Hrin
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Arjun M Bashyam
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Dermatology, University of Southern Denmark, Odense, Denmark
| | - William W Huang
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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34
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El-Amawy HS, Sarsik SM. Saline in Dermatology: A literature review. J Cosmet Dermatol 2020; 20:2040-2051. [PMID: 33098717 DOI: 10.1111/jocd.13813] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/25/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Saline, with its different concentrations, is the most used crystalloid solution in medicine. In dermatology, no large studies investigated the benefits of saline. The aim of this article is to review the different possible uses of saline in dermatology, in order to give final recommendations based on the literature review and our experience. METHODS We performed a literature search based on PubMed, EMBASE, WHO Global Health Library, Virtual Health Library, Web of Science, Scopus, Google Scholar, and Research gate. using the keywords: saline, physiological, hypertonic, isotonic, hypotonic, salt solution, sodium chloride, 0.9% NaCl, solvent, drug delivery, injection mixtures, diluent, sclerosant, intravenous, intralesional, injection, topical, soaks, fomentation, inhalation, alopecia, psoriasis, scars, atopic dermatitis, eczema, bromoderma, iododerma, lipodystrophy, in various combinations with the Boolean operators AND, OR and NOT. We also hand-searched textbooks. RESULTS Saline was used as a diluent with intralesional injection of steroids to minimize the risk of steroid-induced atrophy, being safe and free from preservatives that may precipitate steroids at site of injection and maximize their side effects. Saline has also been used after surgery, when atrophic scars take place or anticipated, and through injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options. CONCLUSIONS The saline represents a helpful option as a diluent with intralesional injection of steroids in various dermatologic therapeutic indications. Moreover, the use of saline in this setting could help to minimize the risk of steroid-induced atrophy. We encourage the use of saline after surgery, when atrophic scars take place or anticipated. Also, we encourage a trial of saline injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.
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Affiliation(s)
- Heba Saed El-Amawy
- Dermatology and Venereology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sameh Magdy Sarsik
- Dermatology and Venereology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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35
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Durgin JS, Shields BE, Rosenbach M. Generalized granuloma annulare: A widespread response to limited application of compounded 2% topical tofacitinib. JAAD Case Rep 2020; 6:1113-1115. [PMID: 33005718 PMCID: PMC7519269 DOI: 10.1016/j.jdcr.2020.07.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Joseph S Durgin
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bridget E Shields
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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36
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Granulomatous Dermatitis and Systemic Disease: An Association to Consider. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3281380. [PMID: 33062676 PMCID: PMC7545450 DOI: 10.1155/2020/3281380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/11/2020] [Accepted: 07/27/2020] [Indexed: 11/28/2022]
Abstract
Granuloma annulare (GA) and interstitial granulomatous dermatitis (IGD) are granulomatous dermatoses with variable clinical appearances. GA is associated with diabetes mellitus, metabolic syndrome, chronic infections, and malignancies, while two Japanese reports described unusual cases of interstitial-type GA in setting of Sjogren syndrome. IGD was associated with rheumatoid arthritis, systemic lupus erythematosus, and autoantibodies. We report a case series of six patients with GA or IGD. Half of the patients were diagnosed with Sjogren syndrome, while all of them presented ANA positivity and the majority reported arthralgia. In many cases, GA showed interstitial-type histology, arising challenges in differential diagnosis with IGD. The overlap of clinical and histological features of GA and IGD can be explained considering them as a broad disease spectrum, including also the other forms of reactive granulomatous dermatitis. These conditions should be considered as an indicator of possible systemic disorders or other immunological dyscrasias, for which patients must be screened. Sjogren syndrome may be associated to GA also in Caucasians.
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37
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García-Malinis AJ, Gracia-Cazaña T, Planas Linares D, Agón-Banzo PJ, Gilaberte Y. Granuloma annulare: report of 13 patients treated with photodynamic therapy. J Eur Acad Dermatol Venereol 2020; 35:e211-e214. [PMID: 32936955 DOI: 10.1111/jdv.16935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - T Gracia-Cazaña
- Unit of Dermatology, Barbastro Hospital, Barbastro, Huesca, Spain
| | | | | | - Y Gilaberte
- Department of Dermatology, University Hospital Miguel Servet, Zaragoza, Spain
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38
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Comorbidities Associated with Granuloma Annulare: A Cross-Sectional, Case-Control Study. MEDICINES 2020; 7:medicines7090053. [PMID: 32872212 PMCID: PMC7554679 DOI: 10.3390/medicines7090053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/04/2022]
Abstract
Background: Granuloma annulare (GA) is a cutaneous granulomatous disorder of unknown etiology. There are conflicting data on the association between GA and multiple systemic conditions. As a result, we aimed to clarify the reported associations between GA and systemic conditions. Methods: A retrospective, cross-sectional, case-control study was performed in which the medical records of biopsy-confirmed GA patients ≥18 years of age, who presented to the Johns Hopkins Hospital System between 1 January 2009 and 1 June 2019, were reviewed. GA patients were compared to controls matched for age, race, and sex. Results: After adjusting for confounders, GA patients (n = 82) had higher odds of concurrent type II diabetes (odds ratio (OR) = 5.27; 95% confidence interval (CI), 1.73–16.07; p < 0.01), non-migraine headache (OR = 8.70; 95% CI, 1.61–46.88; p = 0.01), and a positive smoking history (OR = 1.93; 95% CI, 1.10–3.38; p = 0.02) compared to controls (n = 164). Among GA patients, women were more likely to have ophthalmic conditions (p = 0.04), and men were more likely to have cardiovascular disease (p < 0.01) and type II diabetes (p = 0.05). No differences in systemic condition associations were observed among GA subtypes. Conclusions: Our results support the reported association between GA and type II diabetes. Furthermore, our findings indicate that GA may be associated with cigarette smoking and non-migraine headache disorders.
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39
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Abstract
Perforating granuloma annulare (PGA) is a rare inflammatory condition characterized by transepithelial elimination of necrobiotic collagen with granulomas in the dermis. It commonly presents as umbilicated papules or pustules on the extremities and dorsal hands. The distribution of PGA can be described as generalized or localized, with only 9% of patients presenting with a single lesion. Herein, we report an unusual presentation of PGA as a single localized plaque on the forearm that resembled psoriasis.
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Affiliation(s)
| | | | - Jaime Tschen
- Dermatology, St. Joseph Dermatopathology, Houston, USA
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40
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Diep D, Calame A, Cohen PR. Tinea Corporis Masquerading as a Diffuse Gyrate Erythema: Case Report and a Review of Annular Lesions Mimicking a Dermatophyte Skin Infection. Cureus 2020; 12:e8935. [PMID: 32760635 PMCID: PMC7392473 DOI: 10.7759/cureus.8935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Tinea is a superficial fungal infection of the skin. Gyrate erythemas are reactive conditions that present as annular red lesions. A 61-year-old woman was diagnosed with tinea corporis whose skin lesions morphologically mimicked a gyrate erythema. She presented with diffuse annular plaques affecting the left side of her chest and abdomen that did not respond to a combination antifungal-corticosteroid cream for six-month duration. The appearance and clinical differential diagnosis included a gyrate erythema. Initial evaluation of the skin biopsy from the lesion's edge demonstrated a spongiotic dermatitis, and staining for fungal organisms was negative. However, deeper sections and a different fungal stain revealed hyphae in the stratum corneum and established a diagnosis of tinea corporis. The PubMed database was used to review the following terms: tinea corporis, gyrate erythema, and tinea incognito. Relevant papers and references cited in those papers that were generated by the search were used. Tinea corporis, especially if previously treated with topical corticosteroids, can masquerade as other dermatoses including a gyrate erythema. Correlation of clinical presentation and pathology findings is essential, especially if the biopsy results do not confirm the suspected clinical diagnosis. Consideration to perform deeper sections or additional special stains or both should also be entertained when the initial pathology observations do not support the presumptive diagnosis based on clinical morphology and history.
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Affiliation(s)
- Darlene Diep
- Medicine, Burrell College of Osteopathic Medicine, Las Cruces, USA
| | - Antoanella Calame
- Dermatology/Dermatopathology, Compass Dermatopathology, San Diego, USA.,Dermatology, Scripps Memorial Hospital, La Jolla, USA
| | - Philip R Cohen
- Dermatology, San Diego Family Dermatology, National City, USA
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41
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Megna M, Sidikov A, Ruggiero A, Fabbrocini G, Zaslavsky D, Nasyrov R, Timoshchuk E. A case of generalized granuloma annulare successfully treated by hydroxychloroquine. Dermatol Ther 2020; 33:e13894. [PMID: 32588505 DOI: 10.1111/dth.13894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/17/2020] [Accepted: 06/21/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Matteo Megna
- Department of Dermatology, University of Naples Federico II, Naples, Italy
| | - Akmal Sidikov
- Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation
| | - Angelo Ruggiero
- Department of Dermatology, University of Naples Federico II, Naples, Italy
| | | | - Denis Zaslavsky
- Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation
| | - Ruslan Nasyrov
- Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation
| | - Elena Timoshchuk
- Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation
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42
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Nordmann TM, Kim JR, Dummer R, Anzengruber F. A Monocentric, Retrospective Analysis of 61 Patients with Generalized Granuloma Annulare. Dermatology 2020; 236:369-374. [PMID: 32403113 PMCID: PMC7384347 DOI: 10.1159/000507247] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Granuloma annulare is a chronic noninfectious granulomatous skin condition with variable clinical presentations. Generalized granuloma annulare, defined as widespread disease with >10 skin lesions, accounts for 15% of all cases. Numerous associated diseases have been controversially discussed, most importantly diabetes mellitus, dyslipidemia, thyroid disease, malignancy and systemic infections. OBJECTIVES The objective of our study is to describe disease characteristics, treatment outcome and associated diseases in patients treated at the Department of Dermatology of the University Hospital Zurich during the last 20 years. METHODS The hospital database was searched for patients with generalized granuloma annulare in the last 20 years (January 1, 1998, to December 31, 2017). Overall, 61 patients, 14 males and 47 females, were included in our study. The mean age was 58 years at first consultation. The diagnosis was verified clinically and histologically. RESULTS Generalized granuloma annulare occurred at a mean age of 55 years, more commonly in females. Pruritus was absent in 51% of all patients. Metabolic diseases including diabetes mellitus, hypercholesterinemia and hypertriglyceridemia were present in 10.5, 8.2 and 4.9%, respectively. Thyroid disease was present in 9.8% and malignant disease in 23%, including colorectal cancer, lymphoproliferative disease, squamous cell carcinoma of the esophagus, basal cell carcinoma and gynecological malignancy. Therapy was initiated in 92%, while second- and third-line therapy was performed in 70 and 39%, respectively. Benefit during therapy (e.g., full and partial remission) was achieved in 39.3% during first-line, in 39.4% during second-line and in 33.8% during third-line treatment. Topical corticosteroids were the most commonly prescribed treatment, mostly leading to stable disease (46.6%). Combined full and partial remission occurred in a large proportion of patients receiving UVA1 (45%), PUVA (63.6%) and intralesional triamcinolone acetonide (100%). CONCLUSIONS Generalized granuloma annulare is a mostly asymptomatic and benign disease with a strong tendency for treatment resistance. We suggest to screen all patients for dyslipidemia, thyroid disease and malignant disease. While randomized trials are needed, we suggest topical corticosteroids as the first-line treatment, intralesional triamcinolone acetonide for persistent solitary lesions and, if further treatment is needed, UVA1 or PUVA.
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Affiliation(s)
- Thierry M Nordmann
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Joo-Ri Kim
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Florian Anzengruber
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland,
- Faculty of Medicine, University of Zurich, Zurich, Switzerland,
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Khanna U, North JP. Patch-type granuloma annulare: An institution-based study of 23 cases. J Cutan Pathol 2020; 47:785-793. [PMID: 32279342 DOI: 10.1111/cup.13707] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 03/23/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Granuloma annulare (GA) is a skin disorder of uncertain etiology. Patch (type) GA is an uncommon variant of GA with a paucity of data characterizing it. We describe the features of 23 cases of patch GA. METHODS The archives of dermatopathology were searched for cases of patch GA. The clinical history and morphology for each patient were reviewed. Only cases with patch clinical morphology were included. The clinical and histopathologic features were assessed including the pattern of granulomatous inflammation and presence of other inflammatory cell types. RESULTS Most patients were female (19/23) with erythematous patches on the trunk and proximal extremities. The most common clinical differential diagnosis included mycosis fungoides (MF), morphea and contact dermatitis. Dyslipidemia was the most common comorbidity (30%), followed by diabetes (15%) and hypertension (15%). Histopathologic features included interstitial lymphocytes and histiocytes with dermal mucin. Two cases showed focal palisaded granulomas. Eosinophils and plasma cells were present in 1/3 of cases. CONCLUSION Patch GA is an uncommon GA variant with an interstitial granulomatous histopathologic pattern that predominantly affects women over 50. It can mimic interstitial MF and early morphea both clinically and histopathologically. Awareness of this GA variant can help prevent misdiagnosis and inappropriate treatment for these patients.
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Affiliation(s)
- Urmi Khanna
- Department of Dermatology, University of California, San Francisco, California, USA
| | - Jeffrey P North
- Department of Dermatology, University of California, San Francisco, California, USA.,Department of Pathology, University of California, San Francisco, California, USA
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Abstract
Granulomatous dermatoses comprise a wide range of etiologically and clinically distinct skin diseases that share a common histology characterized by the accumulation of histiocytes include macrophages. While the pathogenesis of these disorders is not fully understood, the underlying mechanism is thought to involve a reaction pattern caused by an immunogenic stimulus. Antigen-presenting cells and the effect of various cytokines play a key role. Our understanding of granulomatous reaction patterns has been advanced by insights drawn from observations of such reactions in patients on immunomodulatory therapy and in individuals with genetic immunodeficiency. Traditionally, a distinction is made between infectious and non-infectious granulomatous dermatoses. The present CME article addresses granulomatous skin diseases for which there is no evidence of a causative infectious agent. Common representatives include granuloma annulare, necrobiosis lipoidica and cutaneous sarcoidosis. Granulomatous dermatoses may be part of the clinical spectrum of various systemic disorders or may be associated therewith. Some neoplastic disorders may mimic granulomatous dermatoses histologically. Given the pathogenetic diversity involved, the clinical presentation, too, is quite varied. Overall, however, each disorder is characterized by typical clinical features. The diagnosis always requires thorough clinicopathologic correlation. Treatment is preferably based on the underlying pathogenesis and frequently involves anti-inflammatory agents. In most cases, however, there is insufficient study data. The dermal nature of these disorders frequently poses a therapeutic challenge, especially with respect to topical treatment.
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Affiliation(s)
- Andrea Schmitt
- DermatoHistologisches Labor Dr. Laaff, Freiburg, Germany
| | - Andreas Volz
- Department of Dermatology, Basel University Hospital, Basel, Switzerland
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Xu Q, Gu Y, Li Y, Ling B, Yu H, Yao Z. Concurrence of generalized perforating and subcutaneous granuloma annulare in a 4‐year‐old boy with latent tuberculosis infection successfully treated with low‐dose hydroxychloroquine. J Dermatol 2019; 47:e71-e72. [PMID: 31762065 DOI: 10.1111/1346-8138.15152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Qianyue Xu
- Department of Dermatology Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Dermatology Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Yan Gu
- Department of Dermatology Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Dermatology Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Yan Li
- Department of Dermatology Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Dermatology Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Bo Ling
- Department of Dermatology Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Dermatology Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Hong Yu
- Department of Dermatology Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Dermatology Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Zhirong Yao
- Department of Dermatology Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine Shanghai China
- Institute of Dermatology Shanghai Jiao Tong University School of Medicine Shanghai China
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Zaouak A, Chamli A, Jouini R, Hammami H, Fenniche S. Patch granuloma annulare of the legs. Presse Med 2019; 48:1200-1201. [PMID: 31471095 DOI: 10.1016/j.lpm.2019.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 07/01/2019] [Accepted: 07/23/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anissa Zaouak
- Dermatology Department, Habib Thameur Hospital, 1008 Tunis, Tunisia; Research Unit "Genodermatoses and cancers" LR12SP03, 1008 Tunis, Tunisia.
| | - Amal Chamli
- Dermatology Department, Habib Thameur Hospital, 1008 Tunis, Tunisia; Research Unit "Genodermatoses and cancers" LR12SP03, 1008 Tunis, Tunisia
| | - Raja Jouini
- Anatomopathology Department, Habib Thameur Hospital, 1008 Tunis, Tunisia; Research Unit "Genodermatoses and cancers" LR12SP03, 1008 Tunis, Tunisia
| | - Houda Hammami
- Dermatology Department, Habib Thameur Hospital, 1008 Tunis, Tunisia; Research Unit "Genodermatoses and cancers" LR12SP03, 1008 Tunis, Tunisia
| | - Samy Fenniche
- Dermatology Department, Habib Thameur Hospital, 1008 Tunis, Tunisia; Research Unit "Genodermatoses and cancers" LR12SP03, 1008 Tunis, Tunisia
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Visconti MJ, Ashack KA, Ashack RJ. Granuloma annulare: strengthening potential associations and pentoxifylline as a therapeutic option. J DERMATOL TREAT 2019; 32:381-382. [PMID: 31464543 DOI: 10.1080/09546634.2019.1662366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Granuloma annulare is frequently described in association with numerous systemic conditions and is often refractory to treatment. This retrospective review explored a large patient cohort to further strengthen associated comorbid conditions and assess response to different treatments in patients with granuloma annulare. This study found that patients with granuloma annulare frequently carried a diagnosis of hypothyroidism. Additionally, the highest rate of improvement in any treatment category was seen with pentoxifylline use. Thus, should be further explored as a first-line therapeutic option in the treatment of granuloma annulare.
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Affiliation(s)
- Michael J Visconti
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Kurt A Ashack
- Department of Dermatology, University of Illinois at Chicago, Chicago, IL, USA
| | - Richard J Ashack
- Dermatology Associates of West Michigan, Michigan State University College of Osteopathic Medicine, Grand Rapids, MI, USA
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48
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Damsky W, Thakral D, McGeary MK, Leventhal J, Galan A, King B. Janus kinase inhibition induces disease remission in cutaneous sarcoidosis and granuloma annulare. J Am Acad Dermatol 2019; 82:612-621. [PMID: 31185230 DOI: 10.1016/j.jaad.2019.05.098] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/20/2019] [Accepted: 05/24/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sarcoidosis and granuloma annulare (GA) are cutaneous granulomatous disorders that can be difficult to treat. There is evidence of underlying Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway activation in sarcoidosis, suggesting that JAK inhibition might be effective. OBJECTIVE To evaluate treatment with tofacitinib, a JAK inhibitor, in patients with recalcitrant sarcoidosis and GA. METHODS A prospective evaluation of tofacitinib in 4 consecutive patients with recalcitrant cutaneous sarcoidosis (n = 3) and generalized GA (n = 1) was conducted. Immunohistochemical analysis of skin biopsy specimens from other patients with sarcoidosis (n = 21) and GA (n = 17) was performed to characterize patterns of JAK-STAT pathway activation. RESULTS Tofacitinib resulted in a mean improvement in the baseline Cutaneous Sarcoidosis Activity and Morphology Instrument and Granuloma Annulare Scoring Index scores of 96% (standard deviation, 2%). Histologic resolution of disease was documented in all patients (3 out of 3) who had skin biopsies while receiving therapy. Constitutive STAT1 and STAT3 activation was observed in both sarcoidosis and GA, albeit in different patterns. Signal regulatory protein α may explain the differences in JAK-STAT signaling between sarcoidosis and GA. LIMITATIONS The study is limited by the small number of participants. CONCLUSIONS Tofacitinib resulted in dramatic improvement in 4 patients with cutaneous sarcoidosis and GA. Larger studies are underway to better understand this effect.
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Affiliation(s)
- William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
| | - Durga Thakral
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Meaghan K McGeary
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Leventhal
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Anjela Galan
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Brett King
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Schmitt A, Volz A. Nicht‐infektiöse granulomatöse Dermatosen. J Dtsch Dermatol Ges 2019; 17:518-535. [DOI: 10.1111/ddg.13848_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Andrea Schmitt
- DermatoHistologisches Labor Dr. Helmut Laaff Freiburg Deutschland
| | - Andreas Volz
- Dermatologische KlinikUniversitätsspital Basel Schweiz
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50
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Kjærsgaard Andersen R, Jemec GBE. Teledermatology management of difficult-to-treat dermatoses in the Faroe Islands. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2019. [DOI: 10.15570/actaapa.2019.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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