Granuloma annulare

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.

Papular Umbilicated Granuloma Annulare in a Patient With Systemic Lupus Erythematosus

Granuloma annulare (GA) is characterized by palisading granuloma, which is histopathologically distinguished by histiocytes arrayed in a palisade configuration encircling insoluble entities associated with degenerated collagen fibrils. The present case demonstrated multiple cutaneous papules showing palisading granuloma in a patient with SLE. A 39-year-old woman has been taking oral prednisolone daily, hydroxychloroquine sulfate, and belimumab for systemic lupus erythematosus (SLE). A few papules appeared on the lateral side of the left arm and gradually increased around both sides. Physical examination found multiple firm skin-colored papules ranging in diameter from 2 to 3 mm on both forearms. Some of the papules had umbilicated tops. Histopathological examination showed degenerated collagen fibers with mucin deposition surrounded by histiocyte infiltrates in the dermis. These findings are characteristic of palisading granuloma. There are several GA variants, such as generalized, subcutaneous, and perforating GA. We considered several possibilities of the mechanisms underlying characteristic histological changes; atypical generalized GA variants, dermatofibroma, and granuloma associated with cutaneous vasculitis. We made the final diagnosis of papular umbilicated GA in the context of SLE.

Clinical Manifestations and Management of Pediatric Granuloma Annulare: A Systematic Review

OBJECTIVE

To determine the clinical manifestations, management, and outcomes of pediatric granuloma annulare.

STUDY DESIGN

We searched MEDLINE via PubMed, Latin American and Caribbean Health Sciences (LILACS), and EMBASE from inception to January 2021. We included all original reports of patients < 18 years of age with a diagnosis of GA and all original reports describing any intervention, including topical or systemic agents, in these patients. Two authors independently extracted socio-demographics and clinical data of the study patients, and treatment(s) used.

RESULTS

Of 2,440 reports screened, 202 were included (836 patients). The mean age was 5.7 (SD 3.8) years and F:M ratio 1.3:1. Localized GA (n=384, 46.8%) and subcutaneous GA (n=353, 43.0%) were the most prevalent subtypes. The most affected site was lower limbs (n=272/568, 47.9%). Suspected triggering factors were mainly local trauma. Diabetes was associated in 22 (2.6%) patients. The rate of spontaneous remission was high (n=140/155, 90.3%), with a median time of 12 months. The most frequent therapies were surgery and topical corticosteroids. Recurrence was observed in 38.3% (n=168/439) of patients, regardless of treatment.

CONCLUSIONS

Pediatric GA frequently resolves spontaneously yet displays a high recurrence rate. Hence, in asymptomatic forms, invasive therapies are not recommended as first-line treatment.

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.

Effects of canary seed on two patients with disseminated granuloma annulare

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. 

Treatment of Generalized Granuloma Annulare with Oral Griseofulvin

Background. Granuloma annulare (GA) is a benign skin disease that has four clinical variants including localized, generalized, perforating, and subcutaneous GA. The most common type is localized GA, followed by generalized GA. Generalized GA was defined as at least 10 widespread annular plagues and frequently on the trunk, face, neck, and extremities. The diagnosis was made by clinical and histopathology. Generalized GA was difficult to treat. Case Presentation. We presented a Thai woman with nonscaly annular papules and plaques on the trunk and all extremities. A skin biopsy revealed a lesion that was compatible with granuloma annulare. She was partially resolved with 2-month course of oral griseofluvin 500 mg daily. Discussion. The regression of GA response to oral griseofulvin is consistent with the inflammatory nature, which identified IFN-gamma upregulated in GA. Conclusion. Griseofulvin is safe with few side effects and cost effectiveness. Further studies are needed to better understand the immunology and pathogenesis of GA.

Pathogenesis of annular lesions: Why a ring presentation?

Annular lesions represent a distinct morphology which characterizes many well-known dermatologic conditions. Little is definitively known regarding the pathogenesis of annular lesions, however there a few well-regarded hypotheses. Lesions that clear centrally while enlarging peripherally may result from a local central tissue anergy, or tolerance. The central area in lesions due to dermatophyte infections or subacute cutaneous lupus erythematous may have a central immunity to the antigen that trigged the lesion. The peripheral spread of inflammatory mediators may also contribute to lesions that expand centrifugally. In a highly active immune response, some of the inflammatory mediators may spread to adjacent tissue, which can propagate the inflammatory reaction. The additional hypotheses regarding pathogenesis are disease specific with individual mechanisms having been proposed. This chapter will describe both general and disease specific mechanisms that may contribute to the formation of annular lesions.

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.

Is biologic therapy the future of granuloma annulare treatment?

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.

Treatment of Granuloma Annulare With Pentoxifylline and Oral Vitamin E: A Case Series

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.

Granulomatous dermatitis following measles, mumps, and rubella vaccination

Granulomatous dermatitis following the administration of various vaccines has previously been reported. However, cases of cutaneous granulomatosis following the measles, mumps, and rubella (MMR) vaccine have not yet been reported. We report the case of a 3-year-old boy with a granuloma annulare-like reaction following MMR vaccination.

Non-Infectious Granulomatous Dermatoses: A Pathologist's Perspective

Granulomatous dermatitis (GD) is one of the commonest tissue reaction patterns encountered in dermatopathology practice. Granulomatous inflammation in the skin can be seen in a wide range of conditions, thus, granulomatous dermatitis always poses significant challenge even to the astute dermatologists and dermatopathologists. Broadly, granulomatous dermatitis is divided into two groups-infectious and non-infectious, the prevalence of both highly variable and show overlapping pathology. However, there are subtle histological clues, which when combined with clinical features, help to narrow down the differential diagnosis. Thus, a good Clinicopathological correlation (CPC) along with histochemical stains, culture and ancillary techniques including molecular studies are required for arriving at a definite diagnosis. In this review, we shall discuss the histological clues to diagnose non-infectious granulomatous dermatitis (NIGD) and their differential diagnoses.

Incidence and Prevalence of Granuloma Annulare in the United States

Importance

Although several single-center studies have estimated that granuloma annulare may account for approximately 0.1% to 0.4% of new patients presenting to dermatologists, large-scale population-based studies estimating the prevalence and incidence of granuloma annulare are lacking.

Objectives

To estimate the population-based incidence and prevalence of granuloma annulare in the United States and to identify the most commonly prescribed treatments.

Design, Setting, and Participants

This cross-sectional study used deidentified data from the Optum Clinformatics Data Mart Database from January 1, 2017, to December 31, 2018, to identify patients with granuloma annulare.

Main Outcomes and Measures

After validating an approach to classify patients with granuloma annulare using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, the primary outcomes were age-, sex-, and race/ethnicity-specific annualized incidence and prevalence estimates for granuloma annulare. In addition, treatment use within 6 to 12 months after the first diagnosis of granuloma annulare was examined. Confidence intervals for prevalence and incidence estimates were computed assuming a binomial distribution using the Wilson score method. Age-, sex-, and race/ethnicity-specific incidence and prevalence estimates were compared using the χ2 test.

Results

A total of 11 608 patients with incident granuloma annulare (8680 female patients [74.8%]; mean [SD] age, 56.5 [18.8] years) and 17 862 patients with prevalent granuloma annulare (13 548 female patients [75.8%]; mean [SD] age, 56.6 [18.5] years) were identified during the study period. The overall annualized incidence of granuloma annulare was 0.04%, or 37.9 (95% CI, 36.9-38.9) per 100 000, and the overall annualized prevalence of granuloma annulare was 0.06%, or 58.3 (95% CI, 57.1-59.5) per 100 000. The incidence and prevalence of granuloma annulare were highest in the fifth decade of life. The incidence and prevalence of granuloma annulare were higher among women (incidence: female to male ratio, 2.8:1; prevalence: female to male ratio, 3.0:1). Within 6 months of their first diagnosis, 4822 patients (41.5%) filled a prescription for a topical corticosteroid, and 1087 patients (9.4%) received an intralesional injection. Within 6 months of their first diagnosis, oral tetracycline prescriptions were filled by 820 patients (7.1%), and hydroxychloroquine prescriptions were filled by 268 patients (2.3%).

Conclusions and Relevance

Granuloma annulare is a rare disease in the United States that is more common among women and middle-aged to older individuals. The findings of this cross-sectional study provide important background regarding the basic epidemiology and overall burden of granuloma annulare in the United States. Future studies are needed to better understand the association of granuloma annulare with quality of life and the most optimal treatment approaches for this condition.

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.

Granuloma annulare subtypes: sonographic features and clinicopathological correlation

PURPOSE

Diagnosis of granuloma annulare (GA) is based on the clinical and histopathological findings. However, only sporadic case reports of subcutaneous GA sonography have been published to date. The objective of this study was to evaluate the ultrasonographic patterns of the different clinical variants of GA: localized, generalized, subcutaneous, and perforating.

METHODS

In this retrospective observational study, we analyzed and correlated the clinical, histopathological, and sonographic features of 15 patients diagnosed with GA.

RESULTS

We included 8 women and 7 men with a mean age of 48.4 years (8-77 years). We found three different sonographic patterns depending on the clinical variant of GA: poorly defined hypoechoic band including the dermis (dermal pattern), irregularly shaped hypoechoic hypodermal lumps (hypodermal pattern), and ill-defined hypoechoic dermal and subcutaneous lesions (mixed pattern). Five cases showed increased blood flow signal on Doppler interrogation.

CONCLUSION

Although our findings are broadly consistent with the previous reports of subcutaneous GA, the sonographic features in localized, generalized, and perforating GA have not been previously reported.

Treatment of granuloma annulare and suppression of proinflammatory cytokine activity with tofacitinib

BACKGROUND

Granuloma annulare (GA) is a common cutaneous inflammatory disorder characterized by macrophage accumulation and activation in skin. Its pathogenesis is poorly understood, and there are no effective treatments. The potential health implications of severe GA are unknown.

OBJECTIVE

We sought to better understand GA pathogenesis and evaluate a molecularly targeted treatment approach for this disease.

METHODS

We used single-cell RNA sequencing to study the immunopathogenesis of GA and also evaluated the efficacy of tofacitinib (a Janus kinase 1/3 inhibitor) in 5 patients with severe, long-standing GA in an open-label clinical trial.

RESULTS

Using single-cell RNA sequencing, we found that in GA lesions IFN-γ production by CD4⁺ T cells is upregulated and is associated with inflammatory polarization of macrophages and fibroblasts. In particular, macrophages upregulate oncostatin M, an IL-6 family cytokine, which appears to act on fibroblasts to alter extracellular matrix production, a hallmark of GA. IL-15 and IL-21 production appears to feed back on CD4⁺ T cells to sustain inflammation. Treatment of 5 patients with recalcitrant GA with tofacitinib inhibited IFN-γ and oncostatin M, as well as IL-15 and IL-21, activity and resulted in clinical and histologic disease remission in 3 patients and marked improvement in the other 2. Inhibition of these effects at the molecular level paralleled the clinical improvement. Evidence of systemic inflammation is also present in some patients with severe GA and is mitigated by tofacitinib.

CONCLUSIONS

The Janus kinase-signal transducer and activator of transcription pathway is activated in GA, likely in part through the activity of IFN-γ and oncostatin M, and Janus kinase inhibitors appear to be an effective treatment.

Granulomatous Skin Diseases in a Tertiary Care Portuguese Hospital: A 10-Year Retrospective Study

Granulomatous skin diseases comprise an extensive group of pathologies whose diagnosis usually requires a histopathological examination. At this level, various types of granulomas can be distinguished, namely tuberculoid, sarcoid, necrobiotic, suppurative, xanthogranuloma, and foreign-body granulomas. This study aimed to determine the frequency and pattern of different granulomatous skin lesions in the Dermatopathology Department of Hospital de Santa Maria (Lisboa, Portugal). A retrospective study of all skin biopsies with granulomatous lesions received during a period of 10 years (2008-2017) was performed. Clinical and histopathological characteristics of the selected cases were analyzed, and the lesions were categorized according to histological type of granuloma and etiology. Foreign-body granulomas secondary to ruptured cyst, folliculitis, or suture material were excluded. From a total of 48,253 cutaneous biopsies performed in this period, 461 (1%) granulomatous lesions were included in our study. In the analysis according to type of granuloma, necrobiotic granulomas were the most frequent (N = 111; 27.0%), followed by sarcoidal (N = 72; 17.5%), tuberculoid (N = 51; 12.4%), suppurative (N = 45; 10.9%), foreign body (N = 40; 9.7%), and xanthogranulomas (N = 26; 6.3%). The remaining 20% corresponded to granulomas of other types. During these 10 years, the most frequent etiology was granuloma annulare (N = 98; 88.3%), followed by sarcoidosis (N = 47; 65.3%). Histopathology is a fundamental tool in the diagnosis of granulomatous skin diseases, allowing for the categorization of various types of granulomas and often guiding further investigation of these patients. The geographical area has an influence on the types of granulomas observed, as evidenced by comparing this study with others previously published.

Saline in Dermatology: A literature review

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.

Adenoid Cystic Basal Cell Carcinoma Arising in Rhinophyma

Adenoid cystic is a rare histological subtype of basal cell carcinoma. Basal cell carcinoma (BCC), the most common form of skin cancer is a slow-spreading tumor with local malignancy, with a high cure rate and favorable prognosis when is diagnosed in the early stages. Rhinophyma is one of the four subtypes of rosacea and it is histopathologically characterized by sebaceous glands hypertrophy. Disseminated annular granuloma (GAD) is a rare inflammatory dermatosis with uncertain etiopathogenesis, clinically represented by papules with annular or arciform aspect. UV radiations aggravates rosacea and are involved in the etiopathogenesis of BCC and can have a triggering or an aggravating effect on GAD. The association of adenoid cystic BCC with rhinophyma it is rare and more than that, the presence of both in association with GAD is not described in medical literature. We present the case of a 78-year old male patient, with personal history of prolonged exposure to UV radiations, that was admitted to the Dermatology for 4 nodular tumors, located on the face. The skin of the nose and menton with thickened, hypertrophied, irregular, red appearance and dilated pores. Also, on the upper limbs and trunk, the patient had, erythematous papules with arciform and ring shape with hypopigmented centers. We performed surgical excision of the tumors and biopsied an annular lesion. Microscopic examination showed nodular basal cell carcinoma with areas of adenoid cystic carcinoma and actinic degeneration of collagen and gigantocellular granulomatous inflammation. The skin biopsied from the upper limb showed annular granuloma appearance.

Pseudolymphomatous Granuloma Annulare: A Case Report

Granuloma annulare is an idiopathic granulomatous condition. Clinical variants of granuloma annulare include classical and localized, large erythematous patch, generalized, perforating, and subcutaneous/deep forms. Rarely, granuloma annulare shows a prominent lymphoid infiltration. This form is called pseudolymphomatous granuloma annulare. Here, we describe a new case of pseudolymphomatous granuloma annulare.

Immunocompromised cutaneous district, isotopic, and isopathic phenomena-Systematic review

BACKGROUND

Although the development of lesions in skin areas that have undergone injury has long been known, understanding of its pathogenesis is limited. Depending on their peculiarities, those events have been described as isomorphic, reverse isomorphic, pseudoisomorphic, isotopic, and isopathic phenomena. Ruocco's immunocompromised cutaneous district (ICD) concept was proposed to include all those phenomena.

AIMS

We performed a systematic review and critically evaluated the current understanding about ICD and its relationship with the isotopic and isopathic phenomena.

METHODS

To illustrate the complexity of the theme, we present a case of subclinical leprosy, whose manifestation was brisk in an old tattoo. The possible interaction between the approached phenomena, acting in the genesis of the disease, made this a pertinent study. The research was conducted under the PRISMA-P guidelines, in seven biomedical databases between 1996 and 2018. The eligibility criteria were systematic reviews, meta-analyses, clinical studies, and case series, written in English, French, Italian, Portuguese, or Spanish.

RESULTS

Using standardized keywords, 1220 articles were identified. After applying the eligibility criteria, 53 studies were selected.

CONCLUSION

This review ratifies that all these phenomena are aspects of one single condition. They can be integrated into the ICD concept with the pathogenesis including: (a) neural damage (peripheral or central) and (b) chronic lymphedema. Both may change the local neuroimmune interaction. The identification of these phenomena and the understanding of their pathogenesis are of paramount importance, to define the diagnosis and choose the therapeutic strategy.

Generalized granuloma annulare associated with essential thrombocythemia

The only myeloproliferative neoplasm associated with generalized granuloma annulare (GA) is chronic myelogenous leukemia (CML). We present the first reported case of GA in a patient with essential thrombocythemia (ET). Future work investigating the shared pathophysiology of GA-associated CML and ET may improve our understanding of GA pathophysiology and treatment.

A Monocentric, Retrospective Analysis of 61 Patients with Generalized Granuloma Annulare

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.