INTRODUCTION Granuloma annulare, also known as pseudorheumatoid nodule, is a benign self-limited lesion of uncertain etiology with characteristic clinical and histopathologic appearance. It has been suggested that lesions are triggered by trauma, insect bites, sun exposure, viral infection, and tuberculin skin tests, but there is no convincing evidence to support these claims. Lesions most often occur on the dorsum of the hands, legs, and trunk, and less frequently on the face and eyelids. Several varieties have been recognized including subcutaneous, generalized, and perforating types. The subcutaneous form occurs most often in children and young adults and is most likely to involve the face. Deep granuloma annulare is a subtype of the subcutaneous form and can involve periosteum and be fixed to bone.
CLINICAL PRESENTATION Lesions present as one or more skin colored erythematous or violaceous dermal plaques, nodules or papules arranged in rings. They are seen most frequently on the lateral upper eyelid and lateral canthus. Lesions appear as nontender mobile cutaneous masses generally less than 1 to 1.5 cm in diameter. Eyelid edema may be moderate, and there may be ptosis of the upper eyelid. With deep lesions they may involve fascia and tendons, and are rubbery in consistency, immobile and often fixed to the orbital rim.
HISTOPATHOLOGY In "classical" granuloma annulare, a palisade of histiocytes surrounds a zone of degenerated collagen containing prominent mucin. The mucin is light blue in sections stained with hematoxylin and eosin, and its presence can be confirmed using alcian blue or colloidal iron stains. In other cases of granuloma annulare, the histiocytes may be interstitial without organization or they may be aggregated but without palisading. Often, there is a mixture of histocytes that are not palisaded, slightly palisaded, and well palisaded. Multinucleated giant cells are usually scant. Usually, all layers of the dermis contain the histiocytic infiltrate. A lower magnification image of granuloma annulare is shown in the terminology chapter under "necrobiosis."
DIFFERENTIAL DIAGNOSIS The differential diagnosis includes insect bites, erythema multiforme, syphilis, rheumatoid nodules, tuberculous granulomas, metastatic lesions, fibrosarcoma, and amyloidosis.
TREATMENT Granuloma annulare lesions tend to be self-limited, resolving over several months without scarring. Therefore, treatment is generally not needed and surgical intervention should be avoided. However, in 20% of cases lesions will recur in the same location and in 26% they will appear at other sites. When treatment is required because of persistence, varying degrees of success have been reported with surgical excision, cryotherapy, radiotherapy, and intralesional steroids.
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