Mariam Alam, MD1
Mollie Oudenhoven, MD2
Molly Weinberg, MD3
Expert Review – Gil Weintraub, MD4
- Differentiate granuloma annulare from other pruritic annular plaques by distinguishing dermal from epidermal involvement.
- Describe the association of granuloma annulare with diabetes mellitus, hypothyroidism, and hyperlipidemia.
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
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.
Take Home Points
- The lack of scale is a good clinical clue that this process does not involve the epidermis, only the dermis.
- Deeper lesions involving the dermis, like granuloma annulare (GA), are often resistant to topical therapies and intralesional triamcinolone is considered first-line treatment.
- Granuloma annulare is associated with diabetes, hypothyroidism and hyperlipidemia. Patients with GA should undergo work up with a HbA1c, TSH and lipid panel.
Granuloma Annulare Images. DermNetNZ. Retrieved 21 June 2021 from https://dermnetnz.org/topics/granuloma-annulare-images/
Vandergriff, TW (2000). Anatomy and Physiology. In Odom, RB, James, WD, Berger, TG, & Andrews, GC. Andrews' diseases of skin: clinical dermatology (pp. 44). WB Saunders.
Odom, RB, James, WD, Berger, TG, & Andrews, GC. Macrophage/Monocyte Disorders. Andrews' diseases of skin: clinical dermatology (pp. 704-707). W.B. Saunders.