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Granuloma annulare is a common benign inflammatory disorder of uncertain pathogenesis that is classically characterized by asymptomatic, flesh-colored to pink or violaceous, nonscaly annular plaques typically located over the dorsa of the hands and feet. (Fig. 359-1) Less common variants include generalized, perforating, and subcutaneous granuloma annulare. The lesions of classic granuloma annulare are round to oval and are often misdiagnosed as tinea corporis (eFig. 359.1). However, unlike tinea infections, the lesions have a smooth, sometimes firm border that lack epidermal scale. Lesions of subcutaneous granuloma annulare appear as asymptomatic to slightly tender, flesh-colored nodules that can occur anywhere, although they are often on the lower legs and scalp. Atypical locations, including the palmar surfaces and eyelids, have reported (eFig. 359.2).1 The differential diagnosis of granuloma annulare includes tinea corporis, necrobiosis lipoidica, rheumatoid nodules, and cutaneous sarcoidosis. Adults who develop this disorder may be more likely to have diabetes, but this association is not seen in children. Histologically, granuloma annulare displays altered collagen and mucin surrounded by distinctive “palisade” of histiocytes. There are also interstitial variants where the collagen alteration is less obvious. In subcutaneous granuloma annulare, the inflammatory process primarily involves the fat. Treatment is generally unsatisfactory. Topical steroids or intralesional steroids can limit progression, but results are not dramatic. Systemic steroids, isotretinoin, hydroxychloroquine, dapsone, and ultraviolet light therapy have been attempted in patients with disseminated granuloma annulare with limited success. Fortunately, granuloma annulare is an indolent process that eventually stabilizes and resolves without scarring over several years.

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Figure 359-1.
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Dorsal hand with annulare granuloma. Note the annular pink plaque with smooth raised borders and no scale.

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eFigure 359.1.
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Annular pink plaque mimicking tinea corporis.

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eFigure 359.2.
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Firm, tender erythematous papule on ventral surface of finger.

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Necrobiosis lipoidica diabeticorum (NLD) is an uncommon inflammatory dermatosis characterized by well-demarcated, yellowish-pink, shiny, atrophic plaques often with prominent central telangiectasia. It is typically, but not exclusively, seen in diabetic patients. Only 0.3% of diabetics develop NLD and its occurrence is independent of glycemic control. Although it is more common in adult females, children with type I and type II diabetes rarely develop NLD. It has been suggested that the presence of NLD may signify an increased risk for nephropathy and retinopathy.2 Despite its relationship to diabetes, the pathogenesis of NLD is uncertain. Lesions most commonly occur on the pretibial region; however, the upper extremities, trunk, and face can be affected. Lesions are typically asymptomatic but can develop ulcerations in response to trauma. Diagnostic evaluation should include a workup for diabetes. Histologically, NLD is characterized by layers of degenerated collagen alternating with granulomatous inflammation in the dermis and subcutaneous tissue. ...

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