Granuloma Annulare

Comprehensive Guide to Granuloma Annulare

Granuloma annulare is a granulomatous skin disease that is accompanied by ring-shaped papules and affects children, adolescents and women in particular. The skin disease is harmless and in many cases regresses without treatment.

What is granuloma annulare?

According to Digopaul, granuloma annulare are benign, nodular papules (skin nodules or vesicles) that mainly appear on the hands and feet and primarily affect children and adolescents.

Ring formation is characteristic of granuloma annulare, which initially manifests itself in the form of white or skin-colored papules, which subsequently recede centrally while simultaneously spreading to the periphery, so that a ring is formed. The skin of the ring is slightly raised and consists of several papules and nodules lined up next to each other.

Granuloma annulare can occur in single or multiple foci (particularly in younger children). In addition, granuloma annulare is generally differentiated between the disseminated form, in which aggregated nodules and papules are distributed throughout the body, and the subcutaneous nodular form, which is primarily associated with nodules in the subcutis (especially on the head, buttocks, and legs)..

Causes

The causes of the manifestation of a granuloma annulare could not be clarified so far. In earlier studies, the disease was often associated with latent diabetes mellitus, but recent research has not been able to demonstrate a statistically significant correlation.

Current studies indicate a connection with a disturbed lipid metabolism, although it is unclear whether the metabolic disturbance is the result or the trigger of a granuloma annulare.

Likewise, cell-mediated or humoral overreactions of the immune system to unknown agents and in individual cases also trauma, excessive exposure to the sun and insect bites are discussed as possible triggering factors. The disseminated form of granuloma annulare is also associated with an underlying HIV infection.

Symptoms, Ailments & Signs

Granuloma annulare is a harmless condition characterized by accumulations of small nodules on specific skin sites. The nodules do not cause itching or pain. Female children and adolescents in particular can be affected by granuloma annulare. The ring-shaped spread of the nodules is typical.

Within a few weeks, ever larger rings of papules form, while the regression of the older nodules is already beginning in the middle of the ring. However, the annular (ring-shaped) nodules will remain for some time (months or even years) without treatment. But they don’t cause any problems. The backs of hands and feet as well as the extensor sides of toes, fingers, feet and hands are particularly affected.

Ring-shaped groups of nodules are sometimes also observed on the forearms and lower legs. Less commonly, the papules also appear on the elbows, trunk, buttocks, or face. There are patients with single rings. However, other sufferers also have multiple rings. Furthermore, some special forms of granuloma annulare are known.

Thus, sometimes in adults, scattered nodules appear on various parts of the body such as the extremities and the entire upper body. In some cases, a connection between HIV infection and this disseminated special form of granuloma annulare could be established. A subcutaneous nodule form is also sometimes found on the head, buttocks, and legs, in which the nodules are located under the unaltered skin.

Diagnosis & History

A granuloma annulare can usually be diagnosed on the basis of the clinical symptoms, in particular the characteristic ring formation caused by the papules typical of the skin disease. In unclear or asymptomatic cases, the diagnosis is confirmed by means of a biopsy followed by histological examination.

Histopathologically, the microscope reveals a barely changed epidermis with necrobiotic areas that show differently degenerated collagen fibers in the corium (also dermis, sclera). Mucopolysaccharides, a greatly increased concentration of glycogen, epithelioid cell granulomas and lymphocyte infiltrates can also be found in the dermis.

In the differential diagnosis, annular granuloma should be differentiated from rheumatic nodules, necrobiosis lipoidica, and annular sarcoidosis. The course and prognosis of granuloma annulare are generally good, and spontaneous regression can be observed in more than half of those affected within 2 years.

Complications

In most cases, annular granuloma does not cause any particular complications or symptoms. Even without treatment, the symptoms usually go away on their own and the disease heals on its own. Those affected suffer from papules, which can be distributed all over the body. The skin is also red in the affected areas and may itch.

In most cases, granuloma annulare occurs on the fingers, hands and feet and can lead to limitations and problems in everyday life. It is not uncommon for this to cause pain when walking, which leads to restricted mobility.

If the pain also occurs in the form of rest pain at night, this pain can lead to sleep disorders and thus to further mental disorders. In general, granuloma annulare has a negative impact on the patient’s quality of life.

In most cases, annular granuloma does not require treatment and will go away on its own. Creams and ointments are only used in severe cases to relieve the symptoms. There is usually no scarring and the patient’s life expectancy is not reduced by the disease.

When should you go to the doctor?

A doctor’s consultation is necessary as soon as skin changes appear on the hands and feet. In children and adolescents in particular, possible abnormalities should be observed and presented to a doctor as soon as possible.

If itching or inner restlessness occurs, this must be observed. If the affected areas are scratched, the wound must be treated sterilely. If this cannot be guaranteed to a sufficient extent with your own aids, you should seek the support of a doctor or a medical assistant.

If circular poplars, ulcers, growths or nodules form on the skin, these abnormalities should be examined and clarified. If the symptoms cause various kinds of impairments in everyday life, a doctor is needed. If you cannot move as usual, if you are subject to one-sided physical strain or if your posture is crooked, you must consult a doctor. There is a risk of permanent dysfunction of the skeletal system.

If the discomfort in the hands or fingers interferes with daily activities such as writing, brushing your teeth or holding objects, you should see a doctor. If, in addition to the physical symptoms, the person concerned complains of sleep disorders, malaise or if he behaves in a strange way, it is advisable to contact a doctor.

Treatment & Therapy

Since a granuloma annulare is usually harmless, does not cause any symptoms and in many cases resolves spontaneously, it does not have to be treated from a purely medical point of view.

However, therapeutic measures are often used for cosmetic reasons, especially in adult patients, in whom regression of the annular granuloma is less common without treatment.

The standard option for this is therapy with glucocorticoids or steroids, which are applied with the help of ointments or creams. In this regard, foil bandages that increase the effectiveness (so-called occlusion therapy), direct intralesional injections of corticoid preparations into the affected skin areas and freezing with liquid nitrogen ( cryotherapy ) have proven effective.

Although topical corticosteroids in occlusal conditions rapidly induce regression of the annular granuloma, potential side effects such as skin atrophy should be considered when choosing therapy given the high rate of spontaneous regression. If the disseminated form of granuloma annulare is present, systemic therapy with dapsone or isoniazid (isonicotinic acid hydrazide) or PUVA therapy may be indicated.

As part of the PUVA therapy, the affected skin areas are irradiated with UVA light in a special phototherapy cabin. The therapy is carried out three to four times a week for a period of several months and usually causes permanent disappearance of the granuloma annulare. In quite a few cases, minor interventions such as biopsy or saline injections can lead to a complete regression of the granuloma annulare.

Outlook & Forecast

The prognosis of granuloma annulare is very favorable. The disease is considered potentially harmless by physicians and scientists and, under normal conditions, does not lead to any severe impairments that would result in a weakening of health. Complications or diseases in the further course of life are also not to be expected.

Normally, the irregularities in the skin’s appearance resolve themselves within a few weeks and without external influences or the administration of medicines. Medical care is not needed for this condition in most patients. The changes in the skin’s appearance can lead to irritation and emotional discomfort in those affected due to the visual flaw.

On the physical level, from a medical point of view, the disease does not trigger any concern or need for action. It is seen as a temporary phenomenon that needs to be assessed at best. When visiting a doctor, the focus is on excluding other skin diseases. It must be clarified that the skin changes can be assigned to the granuloma annulare and that there are no serious disorders.

If psychological problems develop as a result of the optical irregularities, a therapist should be consulted to improve health. There are other issues in the person that are contributing to the deterioration of well-being that should be addressed. Their prognosis must be considered individually.

Prevention

Since the causes of granuloma annulare have not yet been clarified, the skin disease cannot be prevented.

Aftercare

In the case of the disease granuloma annulare, the affected person usually has no options for aftercare. However, these are not necessary either, since this disease is a relatively easy and harmless disease, which in many cases also disappears on its own. Medical treatment is usually only necessary if the granuloma annulare does not heal itself.

In general, the sufferer of granuloma annulare should maintain a high standard of hygiene to prevent the disease from spreading. If the disease does not go away on its own, creams or ointments can also be used to relieve the symptoms. It is important to ensure that it is used regularly.

Even after the symptoms have disappeared, the creams should continue to be used for a few days to completely limit the discomfort. In serious cases, however, treatment by a doctor is necessary. The disease does not negatively affect the life expectancy of those affected.

If granuloma annulare occurs frequently, the reason for its occurrence must be identified in order to avoid the disease. In case of itching, the affected person should not scratch the skin in order to prevent the formation of scars.

You can do that yourself

In many cases, granuloma annulare does not require treatment. If she does not come in with severe symptoms or complications, treatment can be omitted, and the symptoms often go away on their own. As a rule, the patient has various options for self-help to limit the symptoms of the disease.

The use of creams and ointments has a very positive effect on the symptoms of the disease and can limit them considerably. The itching in particular can be eliminated with breastfeeding creams, which often also cool and soothe the skin. In the case of children in particular, it must be pointed out that constant scratching only aggravates the symptoms and can lead to the formation of scars. Scratching should therefore be avoided in any case.

If you have an inferiority complex or low self-esteem, talking to other people affected or to a psychologist often helps. As a rule, a conversation with one’s own partner also has a very positive effect on the illness. Granuloma annulare does not adversely affect the patient’s life expectancy.

Granuloma Annulare

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