Subcutaneous Granuloma Annulare Research Articles

Subcutaneous Granuloma Annulare: A Systematic Review on Current Treatments

Subcutaneous Granuloma Annulare (SGA) is a rare subset of Granuloma Annulare (GA), presenting most often in female children and young adults as a benign, nodular lesion. Etiology is unknown but can be linked to stress, immunologic disorders, connective tissue diseases and diabetes. We searched Scopus, PubMed, Embase, and OVID Medline to assess the current landscape of SGA treatment. We searched (“subcutaneous granuloma annulare” OR “pseudorheumatoid nodules” OR “deep granuloma annulare” OR “palisading granuloma”) AND (“treatment” OR “topical” or “injection”). Articles were limited to English language and human subjects. 302 unique studies were screened and assessed for eligibility by two reviewers working independently with disagreements resolved by a third reviewer’s decision. 33 articles met inclusion comprising case reports (n=27), case series (n=3) and retrospective case reviews (n=3) with a total of 149 patients involved. The most predominant treatment was surgical excision/biopsy (n=112) followed by steroid injection (n=6), topical steroid (n=5), and topical antibiotic (n=3). Reports of one patient responding to treatment (n=1) were reported for local hyperthermia, hydroxychloroquine, cyclophosphamide, oral isotretinoin, PUVA light therapy, and pentoxifylline. Of patients studied in these cases, 17 had spontaneous resolution of their lesions either after the treatment window or before starting treatment. One patient was refractory to targeted treatment but had resolution after achieving diabetic control. While surgical excision predominated, biopsy is standard for diagnosis but follow up was not consistent to assess recurrence. Our review calls for more trials and treatment options for SGA.

Subcutaneous granuloma annulare: a systematic review of a rare and underdiagnosed disease.

Subcutaneous granuloma annulare (SGA) is a rare clinicopathologic subtype of granuloma annulare characterized by the presence of subcutaneous nodules. There are no present reviews synthesizing the clinical features and treatment modalities in SGA. We conducted a systematic review following PRISMA guidelines [CRD42022344672] on all peer-reviewed English-language studies that reported one or more cases of SGA. A total of 97 studies, comprising 26 case series and 71 case reports with 324 patients, were included for analysis. Most cases were predominantly pediatric, with 78.9% of the cases identified being age 16 or lower and a median age of diagnosis of 6. There was no overall gender predisposition. Although over two-thirds of patients did not have any comorbidities, diabetes mellitus was the most common comorbidity present in 4% of cases. The most common feature of SGA was nodules, which were present in 99.6% of patients. Pain or tenderness was reported in 15.4%, and erythema of overlying skin in 11.0% of cases. Surgical excision was performed in 96/141 (68.1%) patients. Among the 27/141 (18.0%) patients who were conservatively managed, 87.0% spontaneously improved, including 60.0% who completely self-resolved. Topical and intralesional steroids were used in 3.40% and 1.85% of patients, respectively, resulting in complete or partial resolution in 54.6% and 100%. Among patients who were followed up, 83/324 (25.6%) patients experienced recurrence after a median duration of 26 weeks. SGA is predominantly a pediatric disease that frequently occurs on the limbs and the head. Juxta-articular lesions are more commonly observed in adults than in children. Surgical excision is common and effective in most patients. Spontaneous improvement occurs in most untreated cases, and intralesional steroids but not topical steroids may be beneficial for non-resolving cases and to reduce time to resolution.

Granuloma annulare and possible relation to purified protein derivative administration: a case report

BackgroundGranuloma annulare is a noninfectious inflammatory granulomatous skin disease characterized by an erythematous or skin colored annulare plaque. The diagnosis of granuloma annulare may be challenging owing to its diverse morphology. In such cases, a correlation between the clinical findings and histologic findings are necessary.Case presentationWe report a case of granuloma annulare after purified protein derivative administration. A 56-year-old Caucasian female patient complained of mildly pruritic rashes which started on both arms and lower extremities, and eventually spread to both thighs, the left popliteal region, left upper back, and the right abdominal area. About 6 weeks prior to the eruption of the rashes, the patient had been given a purified protein derivative tuberculin skin test. Biopsy specimens revealed dermal histiocytes palisading around areas of mucin and degenerated collagen, confirming granuloma annulare. After treatment with 0.1% topical triamcinolone acetanide and 500 mg oral metronidazole, the patient’s lesions resolved.DiscussionRelatively little is known about granuloma annulare’s exact etiology. Granuloma annulare has four variations presenting as either localized, generalized, subcutaneous, or perforating and patch granuloma annulare. The clinical prognosis for granuloma annulare varies according to clinical subtypes. Proposed causal mechanisms of subcutaneous granuloma annulare include physical trauma, infections, immunizations, insect bites, diabetes mellitus, and alterations in the cell-mediated immune responses. The disease likely has an inflammatory component. Clinically, granuloma annulare may be confused with many other skin diseases.ConclusionThis case of subcutaneous granuloma annulare was reported since it is a rare dermatologic pathological condition that can be confused with other skin rash disorders. Although it is a benign self-limited disease, definitive diagnosis is important to rule out other pathologies with similar clinical appearances, such as cancer or human immunodeficiency virus (HIV) infection. Diagnostic confirmation is best made through skin biopsy.

Characterizing Granuloma Annulare in 73 Pediatric Patients.

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. This study aimed to better characterize the epidemiologic and clinical features, triggering factors, disease associations, and outcomes of GA in the pediatric population. We conducted a retrospective study of 73 pediatric patients diagnosed with GA at the University of Rochester Medical Center over a 7-year period. 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. 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.

Relapsing subcutaneous nodules of the penis in a pediatric patient.

A 14-year-old boy presented with a history of non-tender, subcutaneous coalescing nodules located on the ventral-lateral aspects of the penis shaft for one year. Laboratory investigations for blood count and autoimmunity were within normal limits. Complete excision was performed, and on histology, the dermis showed necrobiotic material composed of altered collagen bundles, surrounded by a palisade of histiocytes and scattered lymphocytes, thus allowing a diagnosis of subcutaneous granuloma annulare. Only 18 published cases reported penile granuloma annulare. Medical management was advocated in 7/18 cases, either as a first-line or adjuvant therapy where surgery was not radical. Three patients received high-potency local steroids: two cases underwent adjuvant sessions of intralesional triamcinolone, and one patient received pentoxifylline orally. Surgery should be considered a second-line option since 5/8 of treated cases eventually recurred. The pentoxifylline-treated case witnessed a relapse after drug discontinuation, while topical steroids lead to complete recovery without relapses.

The epifascial cap: A typical imaging sign for subcutaneous granuloma annulare in children.

Subcutaneous granuloma annulare (SGA) is a rare, self-limiting granulomatous disease in children, commonly diagnosed by histopathology following biopsy or surgical excision. This study aimed to identify imaging clues for SGA that could expedite accurate diagnosis and avoid the need for biopsy in children. We retrospectively analyzed complete hospital records of all children diagnosed with SGA at our institution from January 2001 to December 2020. Detailed disease history, imaging findings, management, and outcome were evaluated. We identified 28 patients (20 girls) at a median age of 3.75 (range 1-12.5 years). Ten patients presented with multiple lesions. Most lesions were located on the lower extremities (n = 26/41). Ultrasound examinations were performed on all patients, and 12 (43%) patients also received an MRI. Surgical intervention was conducted in 18 (64%) patients either by incisional biopsy (n = 6) or total excision of the lump (n = 12). In all patients who did not undergo surgery, SGA resolved spontaneously. A careful review of the MRIs led to the discovery of a characteristic imaging shape of SGA lesions: the epifascial cap with a typical broad circular base laying on the fascia, extending towards the subdermal/dermal tissue. This distinctive shape was evident in every patient in our cohort. The "Epifascial Cap Sign" is a specific imaging sign for SGA, which to the best of our knowledge, helps distinguish this disease from other subcutaneous lesions. Recognition of this novel diagnostic sign combined with the historical and physical findings should enable clinicians to establish SGA diagnosis easily and diminish the need for further invasive diagnostic procedures.

Subcutaneous Granuloma Annulare vs. Subcutaneous Vascular Malformations in Children: A Diagnostic Challenge.

There are various subcutaneous lesions in children and often there is difficulty in obtaining an accurate diagnosis by non-invasive diagnostic procedures. Subcutaneous granuloma annulare (SGA) is a rare granulomatous disease that, even after imaging, is often mistaken for a low-flow subcutaneous vascular malformation (SVM). This study aimed to accurately identify clinical and imaging clues to distinguish SGA from low-flow SVM. We retrospectively analyzed complete hospital records of all children with a confirmed diagnosis of SGA and low-flow SVM who underwent MR imaging at our institution from January 2001 to December 2020. Their disease history, clinical and imaging findings, management, and outcome were evaluated. Among 57 patients with granuloma annulare, we identified 12 patients (nine girls) with a confirmed SGA diagnosis who underwent a preoperative MRI. Their median age was 3.25 years (range 2-5 years). Of 455 patients diagnosed with vascular malformations, 90 had malformations limited to the subcutaneous area. Among them only 47 patients with low-flow SVM were included in the study and further analyzed. Our SGA cohort had a female predilection (75%) and a short history of lump appearance of 1.5 months. SGA lesions were immobile and firm. Before MRI, patients underwent initial evaluation by ultrasound (100%) and X-ray (50%). Surgical tissue sampling was performed in all SGA patients to establish a diagnosis. All 47 patients with low-flow SVM were diagnosed correctly by MRI. A total of 45 patients (96%) underwent surgical resection of the SVM. A careful retrospective review of imaging findings of patients with SGA and SVM showed that SGA present as homogenous lesions in the shape of an epifascial cap with a typical broad fascial base extending towards the subdermal tissue in the middle of the lesion. In contrast, SVMs always present with variable-sized multicystic or tubular areas. Our study shows clear clinical and imaging differences between low-flow SVMs and SGA. SGA presents characteristically in the shape of a homogenous "epifascial cap," which distinguishes these lesions from multicystic heterogenous SVMs.

MRI of subcutaneous granuloma annulare: A series of four cases

Background: Subcutaneous granuloma annulare (SGA) is a rare benign soft tissue mass that occurs mostly in the lower limbs of young children. Detailed knowledge of imaging findings is needed to avoid unnecessary invasive diagnostic procedures.
 Materials and Methods: One follow-up case and three companion cases are presented. All children were between the ages of 5 and 10 years.
 Results: The MRI findings demonstrated ill-defined subcutaneous masses in three cases while in one case the mass was mildly hypointense and heterogeneous on fluid-sensitive sequences. Contrast agent was administered intravenously only in one case, where moderate enhancement was observed.
 Conclusion: Detailed clinical description of the lesion location was crucial. In addition, knowledge of MR imaging findings was necessary for a correct diagnosis to reassure the parents and avoid unnecessary invasive diagnostic procedures.

Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase.

Citation: Kaur L, Chakraborty D, Dayal S, Singh S, Yadav K. Subcutaneous Granuloma Annulare in an atypical age group in immediate post-covid phase. Dermatol Pract Concept. 2022;12(4):e2022156. DOI: https://doi.org/10.5826/dpc.1204a156

Juxta-articular nodules with transepidermal elimination in a patient with Raynaud’s phenomenon: the challenging differential diagnosis between rheumatoid nodule and granuloma annulare

We report the case of a 51-year-old female who presented with firm, painful papules and nodules for 9 months, in the extensor proximal metacarpophalangeal and interphalangeal joints in both hands. She did not have a previous diagnosis of rheumatoid arthritis. She also denied arthralgia or arthritis. The patient had livedo reticularis and a history compatible with Raynaud’s phenomenon was reported. The histopathological exam showed well- developed confluent palisaded granulomas with homogenous eosinophilic necrobiosis, with signs of initial transepidermal elimination and no mucin. Thus, we are faced withthe challenging differential diagnosis of rheumatoid nodule preceding rheumatoid arthritis versus perforating juxta-articular granuloma annulare (pseudorheumatoid nodule).

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.

Granuloma anulare profondo

The author describes the case of a three-year-old girl presenting with a firm, painless retroauricular swelling finally diagnosed as deep granuloma annulare.

Giant Subcutaneous Granuloma Annulare

Subcutaneous granuloma annulare is an uncommon, benign self-limiting cutaneous disease, almost exclusively seen in young children. We report a case of 31-year-old male patient, presented with asymptomatic firm plaques over the left lateral malleoli and dorsum of the feet. Histopathological examination was done to confirm the diagnosis and the lesions responded well to monthly doses of the combination of rifampicin, ofloxacin, minocycline (ROM) therapy and intralesional steroid therapy. This case is reported for its unusual presentation of very large plaque in an adult male and its resolution after combined ROM and intralesional steroid therapy.

Subcutaneous granuloma annulare for differential diagnosis of scalp nodules

Subcutaneous granuloma annulare for differential diagnosis of scalp nodules

Granuloma annulare subtypes: sonographic features and clinicopathological correlation.

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. In this retrospective observational study, we analyzed and correlated the clinical, histopathological, and sonographic features of 15 patients diagnosed with GA. We included 8 women and 7 men with a mean age of 48.4years (8-77years). 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. 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.

A Case of Localized Multiple Subcutaneous Granuloma Annulare on the Fingers of a Patient with Mixed Connective Tissue Disease Manifesting Raynaud's Phenomenon

A Case of Localized Multiple Subcutaneous Granuloma Annulare on the Fingers of a Patient with Mixed Connective Tissue Disease Manifesting Raynaud's Phenomenon

Disseminated subcutaneous granuloma annulare in adult

Granuloma annulare (GA) is a common benign inflammatory dermatosis of unknown cause. The subcutaneous form of GA also known as pseudorheumatoid nodule is a relatively uncommon entity, more so in the adult age. We came across a middle-aged female with multiple or disseminated lesions of subcutaneous GA located at an unusual location such as the volar aspect of palms beside the relatively common sites such as elbow and forearm.

Granuloma Annulare: A Focused Review of Therapeutic Options.

Granuloma annulare (GA) is a benign inflammatory disease associated with many conditions such as malignancy, trauma, thyroid disease, diabetes mellitus, and HIV infection. Common clinical subtypes include localized GA, generalized GA, subcutaneous GA, perforating GA, and patch GA. There exists an abundance of literature on GA, yet we know relatively little about its exact etiology and even less about its treatment. The paucity of conclusive data on effective treatment options is largely because the majority of published studies are limited to small case reports, case series, and retrospective studies. As such, there does not yet exist a gold standard of care to guide clinical management. Depending on the clinical subtype, the clinical prognosis for GA can vary. The localized variant generally self-resolves within 2years without treatment, whereas the generalized form is more chronic and less responsive to treatment. This focused up-to-date review serves to summarize the latest therapeutic options available for GA.

ORBITAL DEEP GRANULOMA ANNULARE IN AN ADULT

A granuloma annulare is an idiopathic lesion resembling the granulomas of rheumatic and rheumatoid diseases. It characteristically affects the skin or subcutaneous collagenous structures of children in the absence of systemic disease. Common locations include the lower extremities and scalp, with some reports of lesions affecting the ocular adnexae. Few reports exist of a granuloma annulare confined to the orbit. Despite characteristic histopathological findings, its clinical and radiological presentations pose a challenge for diagnosis. We present an unusual case of an orbital deep granuloma annulare in an otherwise healthy adult male.

Granulomes annulaires profonds multiples céphaliques de l’enfant

Deep granuloma annulare is a fairly rare variety of granuloma annulare. It is seen predominantly in children and mainly affects the anterior aspect of the legs and the top of the feet; cephalic presentation is rare. Below, we report three cases of deep granuloma annulare in children presenting solely at the cephalic extremity. Case 1: a six-year-old boy presented 7cutaneous nodules measuring 1 to 2cm that were flesh-coloured, insensitive to palpation, of hard consistency and deeply attached. The lesions were grouped together on the anterior half of the left temporal fossa. While spontaneous regression of the three nodules was noted in the month following cutaneous biopsy, these nodules recurred a few months later. Case 2: a four-year-old girl with five deep cephalic nodules measuring around one centimetre and the colour of normal skin were seen on her right temporal fossa. The child was lost to follow-up after biopsy. Case 3: a four-month-old infant was presenting some 15deep cutaneous nodules arranged in linear fashion on the forehead next to the left temporal fossa. These nodules regressed spontaneously one month after biopsy. In all three cases, histological examination confirmed the diagnosis of deep granuloma annulare. There have been few published cases of multiple, cephalic, deep granuloma annulare at a single site in children. The condition has an extensive differential diagnosis that includes malignant tumours; in addition, histological confirmation is normally essential. Treatment is not qualified and therapeutic extension with clinical monitoring alone may frequently be recommended.