Granuloma Annulare

Plan to spend 5-10 minutes practicing the flow of the presentation and reviewing the images of squamous cell carcinoma provided.

Present the images by expanding the window below or downloading the PowerPoint file (preferred). Ask the learners to provide a description of the lesions they are viewing. Advance using the arrows or scroll wheel on the mouse to reveal subsequent questions with answers and graphics.

Dermatology description: Pink-red annular (ring-shaped) plaque without scale.

Diagnosis: Granuloma annulare

Teaching:

Question 3: What layer of skin is involved?

The lack of scale is a good clinical clue that this process involves the dermis, not epidermis. The differential for annular rashes includes tinea corporis and psoriasis, however these would have scale, localizing them to epidermis. Deeper lesions involving the dermis, such as GA, are often resistant to topical therapies. Although GA often self-resolves, the time course is unpredictable, and intralesional steroids can be employed for treatment. Topical steroids and topical calcineurin inhibitors can be considered as a treatment choice but are often less effective. Recalcitrant disease may be treated with systemic medications, but this often takes months to be effective.

Question 4: What is your next step in management?

Generalized granuloma annulare is associated with diabetes, thyroid disease and hyperlipidemia, and may be triggered by sun exposure. Patients presenting with GA should undergo work-up for these associated conditions with a HbA1c, TSH and lipid panel.