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Granuloma annulare variability


A patient with interstitial granuloma annulare (GA) manifested by painful acral nodules reminds Dermatologist that GA can present clinically with unusual variations, so that clinicopathologic correlation is important for diagnosis.

Key Points

Lauren Hughey, M.D, assistant professor of dermatology, and Kristin Z. Haushalter, M.D., dermatology resident, report on the case of a 36-year-old Caucasian female who presented with tender, slightly pruritic, erythematous papules on both palms and the distal ends of several fingers. The lateral and dorsal surfaces of her hands and fingers were clear. No lesions were present elsewhere on her body, and the patient had no joint complaints or evidence of systemic disease.

Considering diagnosis

The diagnosis of interstitial GA was made based on the findings from histopathological examination of a biopsy specimen.

"GA is a benign inflammatory dermatosis that typically affects children and young adults. It is usually characterized by asymptomatic, flesh-colored to erythematous annular plaques and dermal papules appearing on the hands and feet, although the face and other regions of the body may be involved, and the lesions may be itchy or painful," Dr. Haushalter tells Dermatology Times.

"However, our patient should remind Dermatologist that GA may present with unusual variations, so a biopsy is essential for accurate diagnosis. To our knowledge, this is the second report of an interstitial type of GA presenting as painful, acral, erythematous nodules."

Patient history

In her history, the patient told Drs. Hughey and Haushalter that the lesions first appeared about two years previously.

They had always been painful and in the same distribution, but would resolve spontaneously and then reappear.

The patient worked as a cosmetologist, but did not find that contact with any particular chemicals induced or exacerbated the eruption. Her past medical history was unremarkable for any previously described inciting factors for GA. The only medication the patient was taking was naproxen for plantar fasciitis, which she had used intermittently for several years.

"The etiology of GA remains unknown, although a variety of entities have been cited in small case series as potential triggers. Those include tuberculosis, insect bites, trauma, viral infections, sun exposure, diabetes mellitus and thyroiditis," Dr. Haushalter says.

Biopsy specimen

Histological examination of the biopsy specimen demonstrated the presence of a dermal interstitial infiltrate composed of histiocytes scattered between collagen bundles along with accumulation of dermal mucin that was identified with colloidal iron staining.

"The more typical palisading granulomas can also be seen on the histologic examination, but mucin deposition is the hallmark of this disease," Dr. Haushalter says.


No treatment was administered for the GA as the patient's lesions had a history of spontaneous resolution.

"Intralesional steroids have been reported effective for interstitial GA, but this patient elected to defer treatment unless her condition worsened or did not resolve. We have been following her in clinic, and the cycle of these lesions appearing and then disappearing has not changed. However, the lesions of interstitial GA may also persist for months to years, so that treatment may be necessary in some cases," Dr. Haushalter says.

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