You are asked to evaluate a toddler who has been covered with ringed plaques for 2 months. His exasperated mother has watched the eruption progress despite treatment with topical antifungal creams. The asymptomatic lesions are generalized but most prominent on the extensor surfaces of his arms and flexural surfaces of his legs. What's the diagnosis?
Diagnosis and Clinical Presentation
The morphology and course of this child's eruption is typical of granuloma annulare. Granuloma annulare is a chronic condition affecting the dermis that is self-limiting and usually asymptomatic. It is found in children and young adults with a female predominance of 2:1. The idiopathic condition is thought to be a type of hypersensitivity reaction. The lesions range from papules to ring shaped plaques and may be skin-colored, violaceous, or erythematous. The lesions are typically found on the trunk and dorsum of the extremities. With granuloma annulare, there is also no increase in other types of inflammatory disorders or rare co-morbidities later on in life (1,2,4). There are four known clinical variants: Localized: This is the most common form of granuloma annulare. The localized form presents with 1-5 cm lesions range from papules to ring shaped plaques. It is common for this form to spontaneously remit in 1-2 years. Generalized/Disseminated: Lesions are the same as the localized variant but the patient will have 10 or more and it may last for up to four years. Perforating: This is a rare form that presents with lesions that may ulcerate and scale. Lesions may also be associated with pain and pruritis (1,2) Subcutaneous: Lesions are subcutaneous nodules and are typically found on the buttocks, lower extremities, hands, and scalp (1,5).
Although usually not necessary, the diagnosis can be confirmed by skin biopsy which shows characteristic non-caseating plaisading granulomas in the dermis and occasionally subcutaneous tissue.
The differential diagnosis in children for granuloma annulare includes tinea corporis, pityriasis rosea, erythema migrans, lichen planus, urticaria, rheumatiod nodules, and eczema. History and physical examination can help to rule out several causes. Potassium hydroxide preparation and fungal culture can rule out tinea. Diagnosis is usually clinical, but can be confirmed by biopsy. (1,2,3)
Treatment for localized granuloma annulare is usually not required. The disease is typically asymptomatic and remission is spontaneous. Topical corticosteroids and intralesional triamcinolone have shown positive results but may result in scarring (2). For disseminated granuloma annulare, there is no definitive treatment, though many forms of therapy have been studied. As with any conditions, one must weigh the clinical outcome with risk of treatment. Various forms of systemic treatment include but are not limited to dapsone, isotretinion, hydroxychloroquine, chloroquine, niacinamide, antralin, PUVA, fumaric acid esters, and topical tacrolimus (1,2).
Our patient was healthy and asymptomatic. We decided upon expectant observation with follow-up in one month.
Granuloma annulare is an innocent, chronic, self-limited, and usually asymptomatic annular eruption commonly occurring in preschool and school age children.
- 1. Wolf K, Johnson RA, Suurmond D (2005). Granuloma annulare. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. New York: McGraw Hill. Retrieved July 22,2008, from Stat!Ref 2. Cyr, PR (2006). Diagnosis and Management of Granuloma Annulare. American Family Physician, 2006;74, 1729-34. 3. Cohen BA, Wang J (2008). Balancing the Scales. Retrieved July 22, 2008, from <http://www.modernmedicine.com/modernmedicine/Dermatology/Balancing-the- scales/ArticleStandard/Article/detail/489872?contextCategoryId=44055> 4. Dahl, MV (2007). Granuloma Annulare: Long-term Follow-up. Archives of Dermatology, 2007;143(7), 946-7. 5. Grogg KL, Nascimento AG (2001). Subcutaneous Granuloma Annulare in Childhood: Clinicopathologic Features in 34 Cases. Pediatrics, 2001;107(3)