Necessary Information about Granuloma Annulare DiagnosticHallmarks

1. Distribution: dorsal feet and hands; elbows and ankles 2.Annular configuration 3. Slowly evolving shapes and sizes 4. Violaceous color

Clinical Presentation

The primary lesion of granuloma annulare is a nonscaIing,dome-shaped or slightly flattened papule 3 to 6 mm in diameter. papules may be skin colored, pink, or violaceous. Lesions on the lowerextremities are more darkly colored than those located elsewhere. The multiplepapules of granuloma annulare are typically arranged in the form of a ring. Thesize of these rings ranges from 1 to 8 cm in diameter. The individual papulesthat make up the border are closely set but may not be completely confluent.This can give a "beaded" appearance to the border. The depressedcenter of the ring is sometimes darker than the papular edge. Multiple ringsare present in about half of the patients. Adjacent rings may grow together,forming a single larger lesion with a polycyclic configuration.

Lesions are most commonly found on the dorsal surface of thefeet and on the dorsal surface of the hands and fingers. The extensor surfacesof the arms and legs (to include the elbows and knees) are also fairlyhabitually involved. Granuloma annulare occurs at any age, but the peakincidence occurs in children aged 4 to 12 years. Lesions are asymptomatic. Aclinical diagnosis can be confirmed by biopsy.

Atypical clinical Presentations

Occasionally, adults will develop a dispersed patternconsisting of hundreds of small rings. The entire body may be involved, butthere may be some predilection for sun-exposed surfaces. Subcutaneous lesionsresembling rheumatoid nodules are occasionally seen in children. Very rarely, online dapsonepapules and nodules of granuloma annulare undergo ulceration (perforatinggranuloma annular). On some occasions, granuloma annulare simulates theappearance of necrobiosis lipoidica diabeticomm (NLD) to point where the twodiseases cannot be distinguished either clinically or histologically. Courseand Prognosis

Individual ringed lesions grow in diameter and sometimeschallge shapes over a period of weeks to months. The course of the disease isselflimited, and usually within 1 or 2 years trace of the lesions hasdisappeared.

Controversy exists as to whether or not there is aupdationship between granuloma annulare and diabetes mellitus, most evidencefavors the lack of a relationship. Pathogenesis

The cause of granuloma annulare is unknown. The lesionshistologically somewhat similar to those of NLD and rheumatoid nodules.Moreover onlinedapsone, clinical overlap between gl"anuloma annulare and NLDcertainly occurs. The significance of these observations is unknown. The locationof granuloma annulare on the hands and feet and an irregular distribution onsun-exposed skin suggest that trauma of some sort plays an etiologic role. Newlesions cannot experimentally be induced in this way, however. In fact,nonspecific truma, such as saline injections, sometimes causes resolution incustomary lesions. A role for immune complex formation and cells-immediatedimmune response in the pathogenesis of granuloma annulare has been suggested bysome studies. Therapy

There is no dependably effective behavior for granulomaannulare, Lesions may respond to high-potency topical steroidsspecially when they are used with occlusion, intralesionally injected steroidsare somewhat more effective. Discomfort during injection and the development ofpostinjection atrophy, however, limit the usefulness of this latter approach. Anumber of other therapies including the use of psoralens-long-wave?lengthultraviolet light (PUV A) and systemically administered chlorambucil anddapsone have been suggested, but proof of dlicacy has not been established.