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Disseminated granuloma annulare - Skin
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Disseminated granuloma annulare - Skin

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Contributors: Tanya Nino MD, Linda Golkar MD, Jeffrey D. Bernhard MD, Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH, Michael D. Tharp MD
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Synopsis

Disseminated granuloma annulare is characterized by widespread (more than 10) annular plaques made up of multiple rather firm pink or flesh-colored papules. These lesions are usually asymptomatic or only mildly pruritic. While granuloma annulare can present with more localized variants, the generalized form may involve the trunk, neck, extremities, face, scalp, palms, and soles. Often times, these lesions have a predilection for skin folds (armpits and groin). Rarely, mucocutaneous involvement can occur.

In contrast to other variants of granuloma annulare, the generalized form predominantly affects children younger than 10 and adults older than 40, has a more prolonged course that may be greater than 3 to 4 years, and is more resistant to treatment. Granuloma annulare does not favor any particular ethnicity or region. Disseminated disease occurs in approximately 15% of patients with granuloma annulare, with a greater incidence in females than males.

Although the etiology of granuloma annulare is poorly understood, there are rare reports of associations with infections, systemic diseases, hematologic malignancies, and solid tumor malignancies. In particular, hypothesized infectious associations are tuberculosis, HIV, Epstein-Barr virus, hepatitis B and C virus, and herpes zoster virus. Systemic diseases reported to have a connection with granuloma annulare are type I diabetes and thyroid disease. Chronic stress has been reported as a trigger. There have also been cases of granuloma annulare following trauma or insect bites. Familial cases have led to the hypothesis of an association with HLA phenotypes. While these factors all may be initiators of granuloma annulare, the mechanism of lesion formation has many possibilities. Current hypotheses include a delayed-type hypersensitivity reaction, a cell-mediated immune response, a cytokine-mediated breakdown of connective tissue, or a primary degeneration of connective tissue with an ensuing granulomatous inflammation.

Codes

ICD10CM:
L92.0 – Granuloma annulare

SNOMEDCT:
402364005 – Generalized granuloma annulare

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Actinic granuloma produces annular plaques similar to those of granuloma annulare but is specifically located in sun-exposed skin.
  • Necrobiosis lipoidica is characterized by shiny red-brown plaques on the lower legs of diabetics that progressively become more yellow and atrophic with time.
  • Tinea corporis may manifest as annular, erythematous plaques with surface changes of scaling, crusting, papules, or vesicles in the advancing border. KOH prep will show branching hyphae.
  • Erythema migrans is the classic targetoid lesion of Lyme disease that shows concentric rings of erythema with central clearing.
  • Erythema annulare centrifugum presents with annular and erythematous plaques with central clearing and a classic trailing scale at the inner rim of the plaque.
  • Urticaria may present with annular plaques, but these lesions will be fleeting in nature, lasting less than 24 hours.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 08/03/2016
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Disseminated granuloma annulare - Skin
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Disseminated granuloma annulare : Scattered many, Smooth plaque, Trunk, Widespread, Annular configuration
Clinical image of Disseminated granuloma annulare
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