Generalized Granuloma Annulare Research Articles

Colchicine vs pentoxifylline vs minocycline for generalized granuloma annulare: A retrospective cohort study

Colchicine vs pentoxifylline vs minocycline for generalized granuloma annulare: A retrospective cohort study

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

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

48 JAK1/2 pathway-specific treatment of generalized granuloma annulare with baricitinib

48 JAK1/2 pathway-specific treatment of generalized granuloma annulare with baricitinib

Results of a treatment algorithm for generalized granuloma annulare

Results of a treatment algorithm for generalized granuloma annulare

44498 Progression of Cutaneous Involvement in Generalized Granuloma Annulare over Time

44498 Progression of Cutaneous Involvement in Generalized Granuloma Annulare over Time

Apremilast in the Management of Generalized Granuloma Annulare: A Case Series

Background: Granuloma annulare is a difficult disease to treat and can lead to anxiety and frustration for both patients and providers. The pathogenesis of granuloma annulare is unknown, resulting in few thoroughly studied or consistently effective treatments.
 Objective: 1) To discuss whether treatment with apremilast could lead to improvement or resolution of generalized granuloma annulare. 2) To explore the possible pathogenesis of granuloma annulare and the mechanism of apremilast in treating this disease.
 Methods: A case series was used to study the clinical response of 6 patients with a history of recalcitrant generalized granuloma annulare taking apremilast 30mg twice daily.
 Results: Two patients achieved complete clearance of their disease without recurrence while the remaining 4 patients achieved significant improvement in lesion number, induration, and erythema.
 Limitations: This is a small case series and larger, controlled trials with long-term follow-up are needed. There is no objective method for evaluating the extent of disease improvement in granuloma annulare. Furthermore, our patients used concomitant topical and intralesional steroids while on apremilast.
 Conclusion: This case series illustrates a novel therapy, apremilast, a phosphodiesterase-4 inhibitor, in the treatment of patients with generalized granuloma annulare and explores possible mechanisms behind the success of this treatment.

PSAT353 Can Generalized Granuloma Annulare occur in patients with Graves’ disease?

Abstract Introduction Granuloma annulare (GA) is a benign self-limiting dermatosis, typically characterized by an annular arrangement of erythematous or flesh-colored papules, affecting patients of all ages. An association between GA and autoimmune diseases (including autoimmune thyroiditis) has been reported in the literature thus suggesting that GA belongs to the spectrum of autoimmune diseases. However, only a few case reports described the unusual association of localized GA with hyperthyroidism. The definitive correlation between thyroid disease and GA hasn't been established. It was suggested that there is a common immunogenic predisposition or that both diseases share a common pathway. We present a rare case of generalized granuloma annulare in a patient with Graves’ disease. Case report A 52-year-old African American female with a past medical history of Graves’ disease with mild Graves’ ophthalmopathy was referred to the endocrinology clinic. She was diagnosed with Graves’ disease seven years ago and was medically managed ever since. Initially, she was treated with a high dose of methimazole however, for the past six years, she was on a stable dose of methimazole 5 mg daily. Two years following diagnosis of Graves’ disease, she developed serpiginous non-pruritic erythematous skin papules and patches in the right upper arm which slowly progressed over the course of years to involve bilateral inner thighs and under the breasts. She was evaluated by dermatology at that time and was empirically treated with a topical antifungal agent without any significant improvements. After establishing care with us, there was suspicion of methimazole-induced ANCA vasculitis or other autoimmune diseases. Extensive rheumatological workup including ANCA level was performed with negative results. Since her thyroid function tests (TSH and free T4) were normal on a low dose of methimazole for an extended period, we discontinued methimazole, however, skin rash didn't improve. The patient was then evaluated by dermatology and was diagnosed with GA based on clinical judgment. She was subsequently treated with an extended course of triple antibiotics therapy using rifampin, ofloxacin, and minocycline for 5 months with significant improvement of the skin rash. Currently, the patient has been off methimazole for 12 months and off triple antibiotic for 4 months with no recurrence of symptoms. Conclusion Although rare, generalized granuloma annulare can be seen in patients with autoimmune thyroid disease including Graves’ disease. Hence, endocrinologists should be aware of the different skin manifestations which can be seen in patients with autoimmune thyroid disease. Further studies are necessary to clarify the association of GA with autoimmune thyroid disease. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

34266 Is generalized granuloma annulare truly associated with diabetes mellitus, hyperlipidemia, thyroid disorders, and malignancy? A systematic review

Objective: Generalized granuloma annulare (GGA) is a rare subtype of granuloma annulare (GA) characterized by its benign, yet chronic recurrent course. Several studies have debated GGA’s association with underlying systemic disease such as diabetes mellitus (DM), dyslipidemia (DLD), malignancy, and thyroid disorders (TD). Our objective was to evaluate the association between GGA and systemic diseases. Methods: The databases PubMed, Embase, and Cochrane Library were searched on June 15, 2021, for “generalized or disseminated granuloma annulare.” Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results: A total of 579 studies were screened for inclusion, yielding 194 studies with 934 patients. The mean age was 51.2 years, and 68.3% of patients were female.The 3 most common associated systemic conditions were DLD (14.6%, n = 136/934), DM (14.5%, n = 135/934), and TD (9.1%, n = 85/934). A total of 93 malignancies (10.0%, n = 93/934) were reported, 69 being non-hematologic malignancies. In total, 35.5% (n = 33/93) of patients had paraneoplastic GGA. Conclusion: Our evidence-based review showed much lower prevalence of DLD, DM, and TD than previous studies. Moreover, only 15 patients experienced resolution of GGA with appropriate management of these comorbidities. Therefore, only a small percentage of patients seem to have a true association of GGA with systemic disease. However, our findings revealed paraneoplastic GGA in 35.5% of patients with underlying malignancy. Therefore, we advocate that it may be beneficial to update age-appropriate cancer screening in individuals with refractory or severe GGA, and history or signs of underlying malignancy.

33823 Update on systemic treatment options for generalized granuloma annulare

Generalized granuloma annulare (GGA) can be difficult to treat. Our institution previously evaluated the efficacy of methotrexate, hydroxychloroquine, and dapsone for GGA. We compared that to unpublished data on pentoxifylline. Institutional review board approval was obtained to retrospectively review records of GGA patients who underwent systemic therapy. All cases were generalized and biopsy-proven. Outcomes were categorized as complete clearance, partial response (fewer, flattened, faded lesions), and no response.

34274 Systematic review of efficacy of treatment options for generalized granuloma annulare

Objective: Generalized granuloma annulare (GGA) is a rare subtype of granuloma annulare (GA) characterized by its benign, yet chronic recurrent course. Currently, evidence-based treatment guidelines are lacking. Therefore, our objective was to conduct a true systematic review to summarize and evaluate the best therapeutic options for GGA.

Malignancy-Associated Generalized Granuloma Annulare in a Japanese Patient with Stomach Cancer and Diabetes Mellitus

Granuloma annulare is a benign granulomatous dermatosis with variable clinical presentation. It is of unknown origin and results in erythematous, brown, or skin-colored annular plaques usually found over boney surfaces on the extremities. The main variants are localized granuloma annulare, subcutaneous granuloma annulare, perforating granuloma annulare, and generalized granuloma annulare. Systemic diseases proposed to have an association with granuloma annulare include diabetes mellitus, dyslipidemia, hypothyroidism, and various malignancies. Cohen [1] coined the term ‘malignancy-associated granuloma annulare’ to describe a form of granuloma annulare that is temporally associated with a malignant process, in which the onset of granuloma annulare coincides with the discovery of a previously unsuspected neoplasm or metastatic disease, and the course of the granuloma annulare also parallels that of the tumor. We present a Japanese patient with malignancy-associated generalized granuloma annulare as the first manifestation of stomach cancer based on diabetes mellitus.

Pentoxifylline in the treatment of generalized granuloma annulare: A report of three cases

Pentoxifylline in the treatment of generalized granuloma annulare: A report of three cases

An evidence-based approach for malignancy-associated and paraneoplastic generalized granuloma annulare

To the Editor: Generalized granuloma annulare (GGA) is a rare subtype of granuloma annulare associated with an underlying systemic disease and malignancy.1-4 Our objective was to conduct an evidence-based review evaluating the association between GGA and malignancy.

26611 Apremilast in the management of generalized granuloma annulare: A case series

This case series evaluates four female patients of ages 29, 61, 66, and 73 years old with a history of recalcitrant generalized granuloma annulare (GA) treated with oral apremilast. All four had previously failed numerous therapies for GA including topical and intralesional steroids, hydroxychloroquine, and narrowband ultraviolet B light phototherapy. Generalized granuloma annulare is a difficult disease to treat and can lead to anxiety and frustration for both patients and providers. The etiopathogenesis of GA is unknown, and as such the disease has few treatments that have been thoroughly studied or consistently effective. This case series illustrates a novel therapy, apremilast, a phosphodiesterase-4 inhibitor, in the treatment of four patients with generalized GA resulting in improvement of their skin disease. The possible etiopathogenesis of GA, as well as the mechanism behind the efficacy of apremilast in treating GA, are both explored. However, larger, controlled trials of apremilast in patients with GA are needed to further evaluate the efficacy of apremilast in the treatment in GA.

Methotrexate for generalized granuloma annulare: A 60% response rate in a retrospective case series of 15 patients

To the Editor: Generalized granuloma annulare (GGA) is a benign granulomatous dermatosis that is plagued by the paucity of high-quality treatment data. The interventions with the most evidence include phototherapy, dapsone, and hydroxychloroquine; however, no regimen appears to produce a reliable response rate.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar Methotrexate (MTX) lacks extensive coverage in the treatment of GGA, and a study of 11 patients with GGA (clinically diagnosed) reported 7 responders (3 with complete resolution and 4 with partial resolution; 64% response rate).2Naka F. Strober B.E. Methotrexate treatment of generalized granuloma annulare: a retrospective case series.J Dermatolog Treat. 2018; 29: 720-724Crossref PubMed Scopus (6) Google Scholar Our group sought to further investigate the safety and efficacy of MTX for GGA using a retrospective case series of 15 patients (with biopsy-proven GGA).Upon Wake Forest School of Medicine's institutional review board approval, a retrospective review of patients with GGA treated with MTX between 2011 and 2021 was performed. Patients without biopsies and patients lost to follow-up were excluded. Outcomes were categorized as complete clearance, partial response (fewer, flattened, and faded lesions), or no response.Fifteen patients—primarily White (93%) women (67%) with a mean age of 61.5 ± 11.3 years—met the inclusion criteria (Table I). The lesions were most commonly plaque type (13/15; 87%) and involved the lower extremities (13/15; 87%), trunk (13/15; 87%), and upper extremities (11/15; 73%). Eleven patients (11/15; 73%) reported pruritus, 4 (4/15; 27%) reported burning pain, and 3 (3/15; 20%) were asymptomatic.Table ICharacteristics and outcomes of 15 patients with generalized granuloma annulare treated with MTXAge, y/sex/raceDisease distributionPre-MTX disease duration, yPre-MTX therapiesMTX dose, mg QW (duration, mo)Concomitant medicationsOutcome (time to response [time from flare, if applicable]), moAdverse effects69/M/WLE and trunk0.5Clobetasol, desonide, and halobetasol7.5 (11)NonePR (4), CC (10)None74/F/WUE, LE, and trunk1Dapsone, HCQ, and TCSs7.5 (17)NonePR (2), CC (11)None54/F/WUE, LE, and trunk3Colchicine10 (23)TAC and topical tacrolimusPR (1); flare, CC (13)None72/M/WTrunk0.5Fluocinonide7.5 (20)Prednisone (6-week taper: from 30 mg to 0 mg), fluocinonide, and TACPR (2), CC (10); flare, CC (13)None67/F/WUE, LE, and trunk∗Disease preceded by varicella infection.1.75Colchicine15 (19)Prednisone (5-week taper: from 30 mg to 0 mg) and TACPR (1); flare, CC (10); flare, NRFatigue72/F/WUE, LE, and trunk5Dapsone, pentoxifylline, and ROM10 (8)NonePR (2)None51/F/WUE and trunk10HCQ17.5 (11)Clobetasol and topical tacrolimusPR (4)Alopecia and stomatitis37/F/WLE0.75TCSs7.5 (19)ILK and TCSsPR (9); flare, PR (4)None68/M/WUE, LE, and trunk0.75Doxycycline, ILK, prednisone, and TCSs15 (16)Acitretin and prednisone (5-week taper: from 30 mg to 0 mg)PR (4)Fatigue56/F/WUE, LE, and trunk∗Disease preceded by varicella infection.5HCQ, phototherapy, ROM, and TCSs7.5 (2)Pentoxifylline and clobetasolNRNone80/F/WUE, LE, and trunk2Clobetasol10 (10)NoneNRNone56/F/XUE, LE, trunk, and face3Adalimumab10 (2)NoneNRNone56/F/WUE, LE, and trunk1.5ILK and TCSs15 (3)TCSsNRFatigue55/M/WUE, LE, and trunk0.75Dapsone, HCQ, prednisone, and ROM12.5 (3)NoneNRElevated ALT level (units per liter) (84)55/M/WLE“Years”HCQ10 (1)NoneNRUnspecifiedALT, Alanine aminotransferase; CC, complete clearance; HCQ, hydroxychloroquine; ILK, intralesional triamcinolone; LE, lower extremities; MTX, methotrexate; NR, no response; PR, partial response; QW, once weekly; ROM, rifampin/ofloxacin/minocycline; TAC, topical triamcinolone; TCI, topical calcineurin inhibitor; TCS, unspecified topical corticosteroid; UE, upper extremities; W, Caucasian; X, other race.∗ Disease preceded by varicella infection. Open table in a new tab The patients were diagnosed with GGA at a mean of 2.5 years prior to MTX exposure. None of the patients were treatment naïve, and systemic therapy failed in 10 patients before MTX was commenced at a median weekly dose of 10 mg for a mean duration of 11 months. Nine (9/15; 60%) patients improved (5 had complete clearance and 4 were partial responders), and the most common concomitant medications in MTX responders were prednisone (3/9; 33%) and topical triamcinolone (3/9; 33%). Initial improvements were observed within a mean of 3 months, and the responders remained on MTX longer than nonresponders (mean 16 vs 3.5 months). GGA flared in 4 (4/9; 44%) responders, including 1 patient who failed to improve with subsequent MTX therapy.Of 7 (7/15; 47%) patients who underwent MTX monotherapy, 3 (3/7; 43%) improved, which was a lower response rate compared with that of patients who were treated with concomitant topical and/or systemic medications (6/8; 75%). Six (6/15; 40%) patients reported side effects, and 2 ceased MTX because of the side effects (stomatitis and alopecia, unspecified). One patient experienced elevated alanine aminotransferase levels (84 units per liter) and discontinued MTX due to a lack of efficacy.This study is limited by its sample size and lack of racial diversity. As with dapsone (54% response rate) and hydroxychloroquine (35% response rate), the responses to MTX neither appeared consistent nor were reliably sustained.3Hrin M.L. Bashyam A.M. Feldman S.R. Huang W.W. Oral dapsone for the treatment of generalized granuloma annulare: a retrospective case series.J Am Acad Dermatol. March 20, 2021; https://doi.org/10.1016/j.jaad.2021.03.045Abstract Full Text Full Text PDF Scopus (4) Google Scholar,4Hrin M.L. Feldman S.R. Huang W.W. Hydroxychloroquine for generalized granuloma annulare: 35% response rate in a retrospective case series of 26 patients.J Am Acad Dermatol. June 30, 2021; https://doi.org/10.1016/j.jaad.2021.06.867Abstract Full Text Full Text PDF Scopus (2) Google Scholar Biologics may be effective options if patients can afford them; in 1 MTX nonresponder, the lesions cleared with adalimumab, but it was discontinued because of its cost.5Chen A. Truong A.K. Worswick S. The role of biologics in the treatment of chronic granuloma annulare.Int J Dermatol. 2019; 58: 622-626Crossref PubMed Scopus (13) Google Scholar Identifying a dependable, accessible treatment for GGA can be challenging. However, MTX may be an economical agent to be considered for patients with recalcitrant disease. To the Editor: Generalized granuloma annulare (GGA) is a benign granulomatous dermatosis that is plagued by the paucity of high-quality treatment data. The interventions with the most evidence include phototherapy, dapsone, and hydroxychloroquine; however, no regimen appears to produce a reliable response rate.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar Methotrexate (MTX) lacks extensive coverage in the treatment of GGA, and a study of 11 patients with GGA (clinically diagnosed) reported 7 responders (3 with complete resolution and 4 with partial resolution; 64% response rate).2Naka F. Strober B.E. Methotrexate treatment of generalized granuloma annulare: a retrospective case series.J Dermatolog Treat. 2018; 29: 720-724Crossref PubMed Scopus (6) Google Scholar Our group sought to further investigate the safety and efficacy of MTX for GGA using a retrospective case series of 15 patients (with biopsy-proven GGA). Upon Wake Forest School of Medicine's institutional review board approval, a retrospective review of patients with GGA treated with MTX between 2011 and 2021 was performed. Patients without biopsies and patients lost to follow-up were excluded. Outcomes were categorized as complete clearance, partial response (fewer, flattened, and faded lesions), or no response. Fifteen patients—primarily White (93%) women (67%) with a mean age of 61.5 ± 11.3 years—met the inclusion criteria (Table I). The lesions were most commonly plaque type (13/15; 87%) and involved the lower extremities (13/15; 87%), trunk (13/15; 87%), and upper extremities (11/15; 73%). Eleven patients (11/15; 73%) reported pruritus, 4 (4/15; 27%) reported burning pain, and 3 (3/15; 20%) were asymptomatic. ALT, Alanine aminotransferase; CC, complete clearance; HCQ, hydroxychloroquine; ILK, intralesional triamcinolone; LE, lower extremities; MTX, methotrexate; NR, no response; PR, partial response; QW, once weekly; ROM, rifampin/ofloxacin/minocycline; TAC, topical triamcinolone; TCI, topical calcineurin inhibitor; TCS, unspecified topical corticosteroid; UE, upper extremities; W, Caucasian; X, other race. The patients were diagnosed with GGA at a mean of 2.5 years prior to MTX exposure. None of the patients were treatment naïve, and systemic therapy failed in 10 patients before MTX was commenced at a median weekly dose of 10 mg for a mean duration of 11 months. Nine (9/15; 60%) patients improved (5 had complete clearance and 4 were partial responders), and the most common concomitant medications in MTX responders were prednisone (3/9; 33%) and topical triamcinolone (3/9; 33%). Initial improvements were observed within a mean of 3 months, and the responders remained on MTX longer than nonresponders (mean 16 vs 3.5 months). GGA flared in 4 (4/9; 44%) responders, including 1 patient who failed to improve with subsequent MTX therapy. Of 7 (7/15; 47%) patients who underwent MTX monotherapy, 3 (3/7; 43%) improved, which was a lower response rate compared with that of patients who were treated with concomitant topical and/or systemic medications (6/8; 75%). Six (6/15; 40%) patients reported side effects, and 2 ceased MTX because of the side effects (stomatitis and alopecia, unspecified). One patient experienced elevated alanine aminotransferase levels (84 units per liter) and discontinued MTX due to a lack of efficacy. This study is limited by its sample size and lack of racial diversity. As with dapsone (54% response rate) and hydroxychloroquine (35% response rate), the responses to MTX neither appeared consistent nor were reliably sustained.3Hrin M.L. Bashyam A.M. Feldman S.R. Huang W.W. Oral dapsone for the treatment of generalized granuloma annulare: a retrospective case series.J Am Acad Dermatol. March 20, 2021; https://doi.org/10.1016/j.jaad.2021.03.045Abstract Full Text Full Text PDF Scopus (4) Google Scholar,4Hrin M.L. Feldman S.R. Huang W.W. Hydroxychloroquine for generalized granuloma annulare: 35% response rate in a retrospective case series of 26 patients.J Am Acad Dermatol. June 30, 2021; https://doi.org/10.1016/j.jaad.2021.06.867Abstract Full Text Full Text PDF Scopus (2) Google Scholar Biologics may be effective options if patients can afford them; in 1 MTX nonresponder, the lesions cleared with adalimumab, but it was discontinued because of its cost.5Chen A. Truong A.K. Worswick S. The role of biologics in the treatment of chronic granuloma annulare.Int J Dermatol. 2019; 58: 622-626Crossref PubMed Scopus (13) Google Scholar Identifying a dependable, accessible treatment for GGA can be challenging. However, MTX may be an economical agent to be considered for patients with recalcitrant disease. Dr Feldman has received research, speaking, and/or consulting support from a variety of companies, including Galderma, GSK/Stiefel, Almirall, Leo Pharma, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Valeant, AbbVie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate, and National Psoriasis Foundation. In addition, he is the founder and majority owner of www.DrScore.com and the founder and part owner of Causa Research, a company dedicated to enhancing patients' adherence to treatment. Drs Bowers and Huang and Author Hrin have no conflicts of interest to declare.

Hydroxychloroquine for generalized granuloma annulare: 35% response rate in a retrospective case series of 26 patients

To the Editor: Granuloma annulare is a benign dermatosis that may present in a localized or generalized distribution (generalized granuloma annulare [GGA]).1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (38) Google Scholar GGA tends to be resistant to therapy, and the challenges surrounding its management are exacerbated by the paucity of data.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (38) Google Scholar Antimalarials have been suggested as a first-line systemic treatment for GGA, and the use of hydroxychloroquine (HCQ) has been supported by a 14-patient case series (64% improvement rate).2Grewal S.K. Rubin C. Rosenbach M. Antimalarial therapy for granuloma annulare: results of a retrospective analysis.J Am Acad Dermatol. 2017; 76: 765-767Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Here, we evaluated the effect of HCQ on patients with GGA using a 26-patient case series. Institutional review board approval was obtained to conduct a retrospective medical record review of GGA patients who received HCQ between 2011 and 2020. Patients without biopsies and those lost to follow-up were excluded. Outcomes were classified as follows: complete clearance, partial response (flattening, fading, and reduction in the number of lesions), or no response. Twenty-six patients—primarily Caucasian (100%), women (92%), and with a mean age of 59 years—met the inclusion criteria (Table I). The most common co-morbid conditions at the time of presentation were dyslipidemia (11/26; 42%), hypothyroidism (10/26; 38%), and type 2 diabetes mellitus (6/26; 23%). Six (6/26; 23%) patients had a history of viral infections (4 with varicella zoster and 2 with herpes simplex). Lesions presented as plaques (18/26; 69%), papules (13/26; 50%), and patches (5/26; 19%), most commonly affecting the upper extremities (23/26; 88%), lower extremities (19/26; 73%), and trunk (19/26; 73%). Twenty (20/26; 77%) patients reported pruritus.Table ITwenty-six patients with biopsy-proven generalized granuloma annulare treated with hydroxychloroquineAge, y/sex/raceLesion distributionPre-HCQ therapiesHCQ duration, mo∗200 mg twice daily unless otherwise specified.Concomitant medicationsResponse (initial response; time from flare, if applicable), moAdverse effects50/F/WFace, neck, and UE†Pretreatment biopsy.Hydrocortisone and terbinafine4NoneCC (4)None67/F/WUE and trunk†Pretreatment biopsy.Selenium sulfide19NonePR (5); CC (7)None70/M/WUE and trunk†Pretreatment biopsy.Pentoxifylline16FluocinonidePR (3); flared, CC (12)None69/F/WUE, LE, and trunk†Pretreatment biopsy.Clobetasol and prednisone16NoneCC (4); flared, PR (6); flared, NRNone57/F/WUE and LE†Pretreatment biopsy.Clobetasol6ClobetasolPR (3)None52/F/WUE and trunk†Pretreatment biopsy.Doxycycline, ILK, TCIs, and TCSs6CalcipotriolPR (6)None46/F/WUE and LE†Pretreatment biopsy.Fluocinonide, ILK, minocycline, MTX, phototherapy, and topical pimecrolimus6FluocinonidePR (1.5); flared, NRNone51/F/WUE, LE, trunk, and neck†Pretreatment biopsy.Colchicine, dapsone, isotretinoin, minocycline, prednisone, and TCSs42DapsonePR (2); flared, no follow-up evaluation at time of analysisNone70/F/WUE, LE, and trunk†Pretreatment biopsy.Minocycline, MTX, prednisone, and TAC48Pentoxifylline and phototherapyPR (3); flared, PR (5)None57/F/WUE, LE, and trunk†Pretreatment biopsy.,‡Post-treatment biopsy.ILK, MTX, and ROM3NoneNRNone74/F/WFace, LE, and trunk†Pretreatment biopsy.Betamethasone, clobetasol, and TAC9TCSsNRPhotosensitivity54/M/WLE†Pretreatment biopsy.TCSs2NoneNRGI upset76/F/WUE and trunk†Pretreatment biopsy.TCSs13TACNRNone36/F/WUE, LE, and trunk†Pretreatment biopsy.TCSs1NoneNRPruritus75/F/WUE, LE, and trunk†Pretreatment biopsy.Cyclosporine, dapsone, and prednisone1NoneNRNone66/F/WUE, LE, and trunk†Pretreatment biopsy.Dapsone6NoneNRNone39/F/WUE, LE, and trunk†Pretreatment biopsy.Clobetasol and TAC8Clobetasol and TACNRHair loss46/F/WFace, UE, and trunk†Pretreatment biopsy.ROM and TCSs2§200 mg once daily.NoneNRGI upset and fatigue65/F/WLE†Pretreatment biopsy.Clobetasol and ROM10PentoxifyllineNRHair loss61/F/WUE and trunk†Pretreatment biopsy.Unknown11TACNRNone55/F/WUE, LE, trunk, and neck‡Post-treatment biopsy.Dapsone, ILK, and TCSs5NoneNRNone57/F/WUE, LE, and trunk†Pretreatment biopsy.Clobetasol, ILK, and phototherapy2NoneNRNone74/F/WUE and LE†Pretreatment biopsy.Hydrocortisone3NoneNRNone55/F/WUE, LE, and trunk†Pretreatment biopsy.Clobetasol, pentoxifylline, and ROM7NoneNRNone54/F/WUE, LE, and trunk†Pretreatment biopsy.Fluocinonide and TAC3Fluocinonide and TACNRDiffuse rash58/F/W‖CLL (3 months preceding GGA).UE and LE†Pretreatment biopsy.Clobetasol, ILK, ROM, and pentoxifylline11ClobetasolNRNoneCC, Complete clearance; CLL, chronic lymphocytic leukemia; GGA, generalized granuloma annulare; GI, gastrointestinal; HCQ, hydroxychloroquine; ILK, intralesional triamcinolone; LE, lower extremities; MTX, methotrexate; NR, no response; PR, partial response; ROM, rifampin/ofloxacin/minocycline; TAC, topical triamcinolone; TCI, topical calcineurin inhibitors; TCS, unspecified topical corticosteroids; UE, upper extremities; W, Caucasian.∗ 200 mg twice daily unless otherwise specified.† Pretreatment biopsy.‡ Post-treatment biopsy.§ 200 mg once daily.‖ CLL (3 months preceding GGA). Open table in a new tab CC, Complete clearance; CLL, chronic lymphocytic leukemia; GGA, generalized granuloma annulare; GI, gastrointestinal; HCQ, hydroxychloroquine; ILK, intralesional triamcinolone; LE, lower extremities; MTX, methotrexate; NR, no response; PR, partial response; ROM, rifampin/ofloxacin/minocycline; TAC, topical triamcinolone; TCI, topical calcineurin inhibitors; TCS, unspecified topical corticosteroids; UE, upper extremities; W, Caucasian. Disease activity existed for a mean of 3 years before the commencement of HCQ dosed at a median 400 mg daily for a mean duration of 10 months. Nine (9/26; 35%) patients improved (4 had complete clearance and 5 were partial responders), and initial responses were observed within a mean of 3.5 months. Five responders (5/9; 56%) flared, including 2 who failed to respond to subsequent HCQ therapy. Thirteen (13/26; 50%) patients underwent HCQ monotherapy. Three (3/26; 12%) patients were administered concomitant systemic treatments (2 responders and 1 nonresponder). Of the HCQ responders, 6 (6/9; 67%) received adjunctive topical (fluocinonide in 2, clobetasol in 1, and calcipotriol in 1) and systemic medications (pentoxifylline in 1 and dapsone in 1). No patient received biologic therapy, which may be effective in patients with GGA.3Chen A. Truong A.K. Worswick S. The role of biologics in the treatment of chronic granuloma annulare.Int J Dermatol. 2019; 58: 622-626Crossref PubMed Scopus (13) Google Scholar Although all the patients were counseled to undergo baseline and annual ophthalmologic evaluations upon HCQ commencement, 13 (13/26; 50%) patients underwent eye examinations. No patient experienced retinal toxicity, and HCQ was generally well tolerated; 19 (19/26; 73%) patients underwent therapy, without adverse effects. The most common discontinuation reason was the perceived lack of efficacy (11/21; 52%). While this study cited a lower response rate (9/26; 35%) than previous studies (9/14; 64%), our case series is not a broadly applicable population (100% Caucasian), and the lack of racial diversity may have attest to the challenges and disparities associated with diagnosing GGA in patients with skin of color.2Grewal S.K. Rubin C. Rosenbach M. Antimalarial therapy for granuloma annulare: results of a retrospective analysis.J Am Acad Dermatol. 2017; 76: 765-767Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar This study is also limited by a lack of a control group and standardized outcome measures. Nevertheless, our results challenge the strength of HCQ as a first-line systemic treatment for GGA; our group recently published data suggesting that improvements are observed more quickly (2.3 months vs 3.5 months) and in higher proportions (54% vs 35%) with dapsone.4Hrin M.L. Bashyam A.M. Feldman S.R. Huang W.W. Oral dapsone for the treatment of generalized granuloma annulare: a retrospective case series.J Am Acad Dermatol. March 20, 2021; (https://doi.org/10.1016/j.jaad.2021.03.045)Google Scholar Small-molecule drugs can be cost-effective treatment options, and additional studies of systemic agents for GGA are warranted. Dr Feldman has received research, speaking and/or consulting support from a variety of companies, including Galderma, GSK/Stiefel, Almirall, Leo Pharma, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Valeant, Abbvie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate, and National Psoriasis Foundation. He is the founder and majority owner of www.DrScore.com and the founder and part owner of Causa Research, a company dedicated to enhancing patients' adherence to treatment. Dr Huang and Author Hrin have no conflicts of interest to declare.

Oral dapsone for the treatment of generalized granuloma annulare: A retrospective case series

To the Editor: Granuloma annulare is a non-infectious granulomatous dermatosis. Although its etiology is unknown, some conditions have been reported in increased frequencies in patients with granuloma annulare compared with the general population, including thyroid disease, diabetes mellitus, dyslipidemia, and viral infections.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar While localized disease tends to spontaneously resolve, generalized granuloma annulare (GGA) cases may persist for decades, and the treatment data are sparse.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar Phototherapy and antimalarials are the first-line treatment for GGA, although retinoids, biologics, and small molecule immunosuppressants can also be used.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar Dapsone may be viable; however, evidence is limited to studies comprising ≤10 patients.2Czarnecki D.B. Gin D. The response of generalized granuloma annulare to dapsone.Acta Derm Venereol. 1986; 66: 82-84PubMed Google Scholar, 3Steiner A. Pehamberger H. Wolff K. Sulfone treatment of granuloma annulare.J Am Acad Dermatol. 1985; 13: 1004-1008Abstract Full Text PDF PubMed Scopus (58) Google Scholar, 4Martín-Sáez E. Fernández-Guarino M. Carrillo-Gijón R. Muñoz-Zato E. Jaén-Olasolo P. Efficacy of dapsone in disseminated granuloma annulare: a case report and review of the literature. Article in Spanish.Actas Dermosifiliogr. 2008; 99: 64-68Crossref PubMed Scopus (19) Google Scholar Here, we evaluate the safety and efficacy of dapsone with a retrospective case series of 26 patients.Institutional review board approval was obtained to review the medical records of patients from a single institution who received oral dapsone for GGA between 2010 and 2020. Patients without pretreatment biopsy and patients lost to follow-up were excluded. Outcomes were categorized as: complete clearance, partial response (fewer, flattened, or faded lesions), or no improvement.Twenty-six patients—primarily Caucasian (100%) women (96%) with a mean age of 64 years—met the inclusion criteria (Table I). Lesions were most commonly plaque-type (24/26; 92%), and involved the lower extremities (23/26; 88%), upper extremities (21/26; 81%), trunk (17/26; 65%), and neck (2/26; 8%); 12 (46%) patients reported pruritus, 4 (15%) patients reported burning pain, and 13 (50%) patients were asymptomatic. The patients had mean disease duration of 5.6 years before initiating dapsone at a median daily dose of 100 mg (25-200 mg) for a mean duration of 9.8 months. Fourteen of 26 (54%) patients improved, and initial responses were observed within a mean of 2.3 months. However, the results were not consistently sustained, and 8 (57%) responders experienced flares following discontinuation. The patients who improved remained on dapsone for longer durations compared with those who did not improve (mean 16.0 vs 2.6 months), and perceived lack of efficacy was the most common discontinuation reason in non-responders (8/12; 67%).Table IPresentation characteristics of 26 patients with generalized granuloma annulare treated with dapsoneAge, y/sex/raceComorbid conditionsGeneralized granuloma annulare disease sitesLesion morphologyPre-dapsone therapiesDapsone maximum daily dose, mg (duration, mo)Adjunctive medicationsOutcome (initial response, mo)Adverse effectsCessation reason74/F/WHypothyroidism, VZVLE, trunkPlaques, patchesClobetasol, topical tacrolimus50 (39)NoneComplete clearance (1)∗Experienced flares after initial response to dapsone.NoneDeath (unrelated)62/F/WHypothyroidism, T2DM, VZVUE, LE, trunkPlaquesNone150 (15)NonePR (0.75)Myelosuppression (3.3 WBC, 11.9 Hg, 137 PLT)Myelosuppression88/F/WNoneUE, LEPlaquesHCQ50 (17)NonePR (1)Myelosuppression (4.6 WBC, 10.5 Hg, 105 PLT)Myelosuppression58/F/WNoneUE, LE, trunkPlaquesColchicine, fluocinonide, MTX, phototherapy, topical tacrolimus100 (13)Clobetasol, topical tacrolimusPR (1)Myelosuppression (4.7 WBC, 10.7 Hg)Myelosuppression76/F/WDLP, hypothyroidismUE, LEPlaques, papulesClobetasol100 (1)PhototherapyPR (1)∗Experienced flares after initial response to dapsone.NauseaNausea59/F/WNoneUE, LE, trunkPlaques, papulesNone100 (10)NonePR (1)NoneUnknown66/F/WHypothyroidismUEPapulesNone150 (39)Clobetasol, pentoxifylline, rifampin/ofloxacin/minocyclinePR (1.5)NoneBenefit plateau66/F/WNoneUEPlaquesMTX, pentoxifylline, phototherapy, prednisone, TCSs150 (13)TACPR (2)∗Experienced flares after initial response to dapsone.UTIUTI44/F/WNoneUE, LEPlaquesNone50 (2)ColchicinePR (2)∗Experienced flares after initial response to dapsone.NoneN/A60/F/WHerpes simplex virusUE, LE, trunkPlaquesNone100 (80)NonePR (3)Myelosuppression (Hg 12.1)Myelosuppression50/F/WT2DM, thyroid nodulesUE, LEPlaquesBetamethasone50 (3)BetamethasonePR (3)∗Experienced flares after initial response to dapsone.Myelosuppression (4.3 WBC, 12.2 Hg, 119 PLT)Myelosuppression51/F/WDLP, hypothyroidism, VZVUE, trunkPlaquesHCQ150 (3)NonePR (3)∗Experienced flares after initial response to dapsone.NoneUnknown63/F/WDLP, hypothyroidism, T2DMUE, LE, trunkPlaquesHCQ, ILK, isotretinoin, MTX, phototherapy75 (22)TACPR (4)∗Experienced flares after initial response to dapsone.NoneBenefit plateau49/F/WNoneUE, LE, trunk, neckPlaques, patchesIsotretinoin, MTX, prednisone, rifampin/ofloxacin/minocycline, TCSs200 (39)PhototherapyPR (8)∗Experienced flares after initial response to dapsone.NoneN/A78/F/WDLP, hypothyroidism, T2DM, VZVLEPlaques, papulesHCQ, TAC100 (1)NoneNIMyelosuppression (4.4 WBC, 11.5 Hg)Myelosuppression80/F/WDLP, T2DMUE, LE, trunkPlaques, papulesFluocinonide50 (1)NoneNIMyelosuppression (10.0 Hg)Myelosuppression61/F/WHypothyroidismUE, LEPlaques, patchesNone150 (1)NoneNINoneLack of efficacy53/F/WNoneUE, LE, trunkPlaquesHalobetasol100 (3)NoneNIDyspnea on exertionLack of efficacy67/M/WT2DMUE, LE, trunkPlaquesHCQ, ILK, phototherapy, TCSs100 (6)NoneNINoneLack of efficacy66/F/WVZVLE, trunkPlaquesTCSs50 (4)NoneNINoneLack of efficacy66/F/WDLP, hypothyroidismUE, LE, trunkPlaquesMTX, TCSs50 (2)NoneNINausea, headache, chills, myalgiasLack of efficacy71/F/WNoneLE, trunkPlaquesAzathioprine, ILK, prednisone, topical pimecrolimus150 (3)NoneNINoneLack of efficacy64/F/WDLP, T2DMLEPlaquesClobetasol, HCQ, pentoxifylline, rifampin/ofloxacin/minocycline25 (0.5)NoneNIUTIUTI55/F/WDLP, hypothyroidism, T2DMUE, LE, trunk, neckPlaques, papulesHCQ, ILK, TCSs25 (6)BetamethasoneNINoneLack of efficacy75/F/WDLPUE, LE, trunkPapules, patchesTCSs100 (0.5)NoneNIMyelosuppression (10.7 Hg)Myelosuppression56/F/WDLPUE, LE, trunkPlaquesAcitretin, prednisone100 (3)NoneNINoneN/ADLP, Dyslipidemia, F, female; HCQ, hydroxychloroquine; Hg, hemoglobin level, g/dL; ILK, intralesional triamcinolone; LE, lower extremities; M, male; MTX, methotrexate; N/A, not applicable; NI, no improvement; PLT, platelet count, ×109/L; PR, partial response; TAC, topical triamcinolone; T2DM, type 2 diabetes mellitus; TCSs, unspecified topical corticosteroids; UE, upper extremities; UTI, urinary tract infection; W, Caucasian; WBC, white blood cell count, ×109/L; VZV, Varicella zoster virus.∗ Experienced flares after initial response to dapsone. Open table in a new tab Seventeen of 26 (65%) patients underwent dapsone monotherapy, including 6 of 13 (46%) responders. The most common concomitant medications in those who improved with dapsone were topical corticosteroids: betamethasone (2/14; 14%), clobetasol (2/14; 14%), and triamcinolone (2/14; 14%). Several agents were attempted before dapsone treatment but failed to yield results or caused unbearable side effects (Table I). Although dapsone was subjectively well-tolerated (2 patients complained of nausea), nearly 1 in 3 patients (8/26; 31%) experienced subclinical myelosuppression (median 12 months after initiating dapsone), which warranted treatment cessation. Dapsone is associated with a variety of local and systemic adverse effects that may preclude its viability.5Ghaoui N. Hanna E. Abbas O. Kibbi A.G. Kurban M. Update on the use of dapsone in dermatology.Int J Dermatol. 2020; 59: 787-795Crossref PubMed Scopus (28) Google ScholarThe management of GGA can be challenging. Granulomatous inflammation can be slow to both form and resolve, and the effects of therapy may not be observed for 3-6 months.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar The evidence to support dapsone for GGA remains debatable as clinical responses may not be durable nor consistently achieved, and the patients may experience treatment-limiting side effects. However, these results contribute to the limited pool of data for a condition which has no definitive treatment option. To the Editor: Granuloma annulare is a non-infectious granulomatous dermatosis. Although its etiology is unknown, some conditions have been reported in increased frequencies in patients with granuloma annulare compared with the general population, including thyroid disease, diabetes mellitus, dyslipidemia, and viral infections.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar While localized disease tends to spontaneously resolve, generalized granuloma annulare (GGA) cases may persist for decades, and the treatment data are sparse.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar Phototherapy and antimalarials are the first-line treatment for GGA, although retinoids, biologics, and small molecule immunosuppressants can also be used.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar Dapsone may be viable; however, evidence is limited to studies comprising ≤10 patients.2Czarnecki D.B. Gin D. The response of generalized granuloma annulare to dapsone.Acta Derm Venereol. 1986; 66: 82-84PubMed Google Scholar, 3Steiner A. Pehamberger H. Wolff K. Sulfone treatment of granuloma annulare.J Am Acad Dermatol. 1985; 13: 1004-1008Abstract Full Text PDF PubMed Scopus (58) Google Scholar, 4Martín-Sáez E. Fernández-Guarino M. Carrillo-Gijón R. Muñoz-Zato E. Jaén-Olasolo P. Efficacy of dapsone in disseminated granuloma annulare: a case report and review of the literature. Article in Spanish.Actas Dermosifiliogr. 2008; 99: 64-68Crossref PubMed Scopus (19) Google Scholar Here, we evaluate the safety and efficacy of dapsone with a retrospective case series of 26 patients. Institutional review board approval was obtained to review the medical records of patients from a single institution who received oral dapsone for GGA between 2010 and 2020. Patients without pretreatment biopsy and patients lost to follow-up were excluded. Outcomes were categorized as: complete clearance, partial response (fewer, flattened, or faded lesions), or no improvement. Twenty-six patients—primarily Caucasian (100%) women (96%) with a mean age of 64 years—met the inclusion criteria (Table I). Lesions were most commonly plaque-type (24/26; 92%), and involved the lower extremities (23/26; 88%), upper extremities (21/26; 81%), trunk (17/26; 65%), and neck (2/26; 8%); 12 (46%) patients reported pruritus, 4 (15%) patients reported burning pain, and 13 (50%) patients were asymptomatic. The patients had mean disease duration of 5.6 years before initiating dapsone at a median daily dose of 100 mg (25-200 mg) for a mean duration of 9.8 months. Fourteen of 26 (54%) patients improved, and initial responses were observed within a mean of 2.3 months. However, the results were not consistently sustained, and 8 (57%) responders experienced flares following discontinuation. The patients who improved remained on dapsone for longer durations compared with those who did not improve (mean 16.0 vs 2.6 months), and perceived lack of efficacy was the most common discontinuation reason in non-responders (8/12; 67%). DLP, Dyslipidemia, F, female; HCQ, hydroxychloroquine; Hg, hemoglobin level, g/dL; ILK, intralesional triamcinolone; LE, lower extremities; M, male; MTX, methotrexate; N/A, not applicable; NI, no improvement; PLT, platelet count, ×109/L; PR, partial response; TAC, topical triamcinolone; T2DM, type 2 diabetes mellitus; TCSs, unspecified topical corticosteroids; UE, upper extremities; UTI, urinary tract infection; W, Caucasian; WBC, white blood cell count, ×109/L; VZV, Varicella zoster virus. Seventeen of 26 (65%) patients underwent dapsone monotherapy, including 6 of 13 (46%) responders. The most common concomitant medications in those who improved with dapsone were topical corticosteroids: betamethasone (2/14; 14%), clobetasol (2/14; 14%), and triamcinolone (2/14; 14%). Several agents were attempted before dapsone treatment but failed to yield results or caused unbearable side effects (Table I). Although dapsone was subjectively well-tolerated (2 patients complained of nausea), nearly 1 in 3 patients (8/26; 31%) experienced subclinical myelosuppression (median 12 months after initiating dapsone), which warranted treatment cessation. Dapsone is associated with a variety of local and systemic adverse effects that may preclude its viability.5Ghaoui N. Hanna E. Abbas O. Kibbi A.G. Kurban M. Update on the use of dapsone in dermatology.Int J Dermatol. 2020; 59: 787-795Crossref PubMed Scopus (28) Google Scholar The management of GGA can be challenging. Granulomatous inflammation can be slow to both form and resolve, and the effects of therapy may not be observed for 3-6 months.1Wang J. Khachemoune A. Granuloma annulare: a focused review of therapeutic options.Am J Clin Dermatol. 2018; 19: 333-344Crossref PubMed Scopus (37) Google Scholar The evidence to support dapsone for GGA remains debatable as clinical responses may not be durable nor consistently achieved, and the patients may experience treatment-limiting side effects. However, these results contribute to the limited pool of data for a condition which has no definitive treatment option. Dr Feldman has received research, speaking, and/or consulting support from a variety of companies including Galderma , GSK / Stiefel , Almirall , Leo Pharma , Boehringer Ingelheim , Mylan , Celgene , Pfizer , Valeant , Abbvie , Samsung , Janssen , Lilly , Menlo , Merck , Novartis , Regeneron , Sanofi , Novan , Qurient , National Biological Corporation , Caremark , Advance Medical , Sun Pharma , Suncare Research , Informa , UpToDate , and National Psoriasis Foundation and is the founder and majority owner of www.DrScore.com and the founder and part owner of Causa Research, a company dedicated to enhancing patients' adherence to treatment. Authors Hrin, Bashyam, and Huang have no conflicts of interest to declare.

A Review of the Dermatological Complications of Giant Cell Arteritis.

Giant cell arteritis (GCA) is characterized by granulomatous inflammation of large and medium-sized vessels. It is the most common vasculitis among elderly people in Europe and North America. GCA usually presents with ischemic cranial manifestations such as headache, scalp tenderness, visual manifestations, and claudication of the tongue and jaw. Thickness and tenderness of temporal arteries are the most recognizable signs of GCA on physical examination. Laboratory tests usually show raised acute phase reactants. Skin manifestations are uncommon in GCA and are rarely found as a presenting symptom of GCA. Necrosis of the scalp and tongue is the most common ischemic cutaneous manifestation of GCA. Although infrequent, when present it reflects severe affection and poor prognosis of GCA. Panniculitis-like lesions have been reported in the setting of GCA, with nodules being the most common finding. Other entities, such as generalized granuloma annulare or basal cell carcinoma have been occasionally described in GCA patients. Prompt recognition and initiation of therapy are crucial to prevent serious complications of GCA. When high suspicion of GCA exists, immediate administration of glucocorticoids is recommended. It is advisable to refer the patient to a specialist GCA team for further multidisciplinary assessment.

Localized Versus Generalized Granuloma Annulare: A Retrospective Review of 407 Patients.

Granuloma annulare has been linked to diabetes, dyslipidemia, thyroid disease, collagen vascular disease, malignancies, infectious hepatitis, and systemic infections. However, these associations have not been systematically investigated when categorized by its clinical variants. To evaluate disease associations of localized and generalized granuloma annulare. In total, 407 granuloma annulare patients from 1989 to 2019 were retrospectively reviewed, categorized by clinical variant (localized or generalized), age (pediatric or adult), and diagnostic method (clinical or histologic). Descriptive statistical analyses and multivariate logistic regression analysis were performed. Fisher's exact tests were conducted to produce unbiased probability values. Overall, 75.2% of the study sample was female, 47.2% had dyslipidemia, 24.8% were diabetic, and 24.6% had thyroid disease. Dyslipidemia (OR 2.15, CI 1.95-2.35, P < .001), diabetes (OR 1.16, CI 1.01-1.31, P = .041), and histologic diagnosis (OR 2.08, CI 1.21-3.52, P = .007) were associated with increased risk of GGA compared to LGA. When stratified by adult versus pediatric cases, dyslipidemia and diagnostic method remained significant, but diabetes did not. Evaluating granuloma annulare by its clinical variants may help to determine disease associations with each variant.

A case of generalized granuloma annulare successfully treated by hydroxychloroquine

Dermatologic TherapyVolume 33, Issue 6 e13894 LETTER A case of generalized granuloma annulare successfully treated by hydroxychloroquine Matteo Megna, Corresponding Author Matteo Megna mat24@libero.it orcid.org/0000-0003-1803-2046 Department of Dermatology, University of Naples Federico II, Naples, Italy Correspondence Matteo Megna, Department of Dermatology, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy. Email: mat24@libero.itSearch for more papers by this authorAkmal Sidikov, Akmal Sidikov Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this authorAngelo Ruggiero, Angelo Ruggiero orcid.org/0000-0002-4658-7391 Department of Dermatology, University of Naples Federico II, Naples, ItalySearch for more papers by this authorGabriella Fabbrocini, Gabriella Fabbrocini orcid.org/0000-0002-0064-1874 Department of Dermatology, University of Naples Federico II, Naples, ItalySearch for more papers by this authorDenis Zaslavsky, Denis Zaslavsky orcid.org/0000-0001-5936-6232 Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this authorRuslan Nasyrov, Ruslan Nasyrov Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this authorElena Timoshchuk, Elena Timoshchuk Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this author Matteo Megna, Corresponding Author Matteo Megna mat24@libero.it orcid.org/0000-0003-1803-2046 Department of Dermatology, University of Naples Federico II, Naples, Italy Correspondence Matteo Megna, Department of Dermatology, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy. Email: mat24@libero.itSearch for more papers by this authorAkmal Sidikov, Akmal Sidikov Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this authorAngelo Ruggiero, Angelo Ruggiero orcid.org/0000-0002-4658-7391 Department of Dermatology, University of Naples Federico II, Naples, ItalySearch for more papers by this authorGabriella Fabbrocini, Gabriella Fabbrocini orcid.org/0000-0002-0064-1874 Department of Dermatology, University of Naples Federico II, Naples, ItalySearch for more papers by this authorDenis Zaslavsky, Denis Zaslavsky orcid.org/0000-0001-5936-6232 Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this authorRuslan Nasyrov, Ruslan Nasyrov Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this authorElena Timoshchuk, Elena Timoshchuk Department of Dermatovenereology, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian FederationSearch for more papers by this author First published: 25 June 2020 https://doi.org/10.1111/dth.13894Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume33, Issue6November/December 2020e13894 RelatedInformation