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LETTER TO THE EDITOR
Year : 2012  |  Volume : 3  |  Issue : 1  |  Page : 74-76  

Generalized papular granuloma annulare


Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication3-Mar-2012

Correspondence Address:
Manish Bansal
Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh - 221 005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.93492

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How to cite this article:
Bansal M, Pandey SS, Manchanda K. Generalized papular granuloma annulare. Indian Dermatol Online J 2012;3:74-6

How to cite this URL:
Bansal M, Pandey SS, Manchanda K. Generalized papular granuloma annulare. Indian Dermatol Online J [serial online] 2012 [cited 2019 Nov 13];3:74-6. Available from: http://www.idoj.in/text.asp?2012/3/1/74/93492

Sir,

Granuloma annulare (GA) is a benign, inflammatory dermatosis with no proven etiology. It involves dermis or subcutis in a process characterized by necrobiosis surrounded by lymphohistiocytes. Various morphological forms are described, including localized, generalized, perforating and subcutaneous. [1] Generalized GA (GGA) is a rare variant seen in 8−15% of cases. Multiple skin colored, pink, or violaceous papules coalescing to form annular plaques are the commonest presentation of the GGA, but the distinctive papular morphology in the absence of the plaques is a rare phenomenon for the generalized variety and presents a diagnostic dilemma. We report this case for the rarity of isolated papular presentation of the disease.

A 75-year-old female presented with multiple skin colored papules over trunk for 6 months associated with moderate pruritus. The lesions started from neck, upper chest and involved trunk, arms and thighs in a span of 4 weeks. Patient had no history of diabetes mellitus, hypertension, or drug ingestion. On examination there were numerous, discrete skin colored papules, 0.5−1 cm in size, over upper chest, abdomen, lateral aspect of arms and thighs in bilaterally symmetrical pattern [Figure 1]. Hair, nail, and mucosae were normal. Laboratory investigations showed severe microcytic hypochromic anemia with hemoglobin - 5.3 gm% (normal: 11−16 mg/dl). Random blood sugar, liver and renal function tests, urinalysis, chest X-ray, fasting lipid profile, antinuclear antibodies, and thyroid profile were normal. Elisa for Human immunodeficiency virus (HIV) 1 and 2 was nonreactive. Histopathological examination from a papule on upper trunk showed palisading granuloma in mid-reticular dermis around focus of mucin and incomplete collagen degradation [Figure 2]. The granuloma consisted of lymphohistiocytes with giant cells forming a semicircular palisade [Figure 3]. Rest of dermis showed perivascular lymphocytic infiltrate. After clinic-pathological correlation, diagnosis of generalized papular GA was made. Most of lesions regressed spontaneously in 4 weeks.
Figure 1: Multiple skin colored papular lesions on anterior upper chest

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Figure 2: Palisading granuloma in mid-reticular dermis around focus of mucin deposition and necrobiosis (H and E, ×100)

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Figure 3: Lymphohistiocytic infiltrate along with giant cells forming the granuloma (H and E, ×400)

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GA is a granulomatous disease characterized by multiple erythematous, annular plaques with histopathological features of necrobiosis and granuloma formation. [2] The etiology of GA is unknown. Mild trauma in form of insect bite, tuberculosis test, or phototherapy is considered a possible triggering factor. Certain viral infections like Epstein Barr, Herpes zoster, and HIV are linked to etiology. Familial cases are also reported. [3] Few drugs have been implicated like gold and allopurinol. It is occasionally symptomatic with variable pruritus and resolves spontaneously. Association with diabetes mellitus is controversial. [4] Reports have suggested an association of GGA with autoimmune thyroiditis and lipid profile abnormalities. [4] GA may represent a paraneoplastic response to certain malignancy like lymphoma. Tendency of GA to remit spontaneously complicates accurate assessment of efficacy of treatment. Various treatment modalities that have been tried include topical steroids, cryosurgery, phototherapy, dapsone, retinoids, cyclosporine, chlorambucil, antimalarials, niacinamide, vitamin E, pentoxifylline, infliximab, topical imiquimod, and calcineurin inhibitors. [5]

Isolated papular morphology of GA in the absence of the typical plaques is a rare presentation and often misleads the physician. Therefore, the diagnosis of papular GA must be considered in such a presentation and confirmed by histopathological examination as it has distinctive histopathological picture of necrobiosis, granuloma formation and mucin deposition.

 
   References Top

1.Prendiville SJ. Granuloma annulare. In: Fitzpatrick TB, Wolff K, Goldsmith AL, Gilchrest AB, Paller SA, Leffell JD, editors. Dermtology in General Medicine. 7 th ed. New York, NY: Mc-Graw-Hill; 2008. p. 369-72.  Back to cited text no. 1
    
2.Ko CJ, Glusac EJ, Shapiro PE. Noninfectious granulomas. In: Elder DE, Elenitsas R, Johnson BL, Murphy GF, editors. Lever's Histopathology of the skin. 10 th ed. Philadelphia: Lippincott Williams and Williams; 2009. p. 361-3.  Back to cited text no. 2
    
3.Friedman SJ, Winkelmann RK. Familial granuloma annulare. Report of two cases and review of the literature. J Am Acad Dermatol 1987;16:600-5.  Back to cited text no. 3
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4.Goucha S, Khaled A, Kharfi M, Fazaa B, Zermani R, Ben Jilani S, et al. Granuloma annulare. G Ital Dermatol Venereol 2008;143:359-63.  Back to cited text no. 4
[PUBMED]    
5.Peggy R. Diagnosis and management of granuloma annulare. Am Fam Physician 2006;74:1729-34.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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