Etiology, Diagnosis, and Therapeutic Management of Granuloma Annulare

An Update

Laura A. Thornsberry; Joseph C. EnglishIII


Am J Clin Dermatol. 2013;14(4):279-290. 

In This Article

2 Clinical Presentation

The skin manifestations of GA are polymorphic owing to the many variants of the disease, including localized, generalized (including generalized annular, disseminated papular, and atypical generalized GA), subcutaneous, and perforating. In localized GA, annular groups of skin-colored to erythematous papules most commonly occur on the dorsal hands and/or feet (Fig. 1a, b). Localized GA occurs most commonly in patients under the age of 30 years old, with a 2:1 female to male predominance and no racial predilection.[1] This form accounts for about 75 % of GA cases.[2] Generalized GA is defined by the simultaneous presence of at least ten skin lesions or by widespread annular plaques and occurs in about 8–15 % of patients with GA (Fig. 2a, b).[3] Disseminated GA consists of scattered skin-colored to erythematous papules (Fig. 3a, b). Atypical generalized GA consists of widespread granulomatous lesions that do not fit the description of annular or disseminated GA (Fig. 4a, b). Generalized GA is more likely to occur in middle-aged or older patients.[4] A recent retrospective study of 54 Korean patients with generalized GA showed this form occurring predominantly in patients younger than 10 years old or older than 40 years old with a slight male predominance.[5] Subcutaneous GA, also known as pseudorheumatoid nodules, is more common in children and consists of firm subcutaneous nodules, often on the lower legs.[6] The perforating variant of GA is clinically distinct from the other forms because of central umbilication of the lesions secondary to the elimination of collagen. Other reported rare subtypes of GA include macular or patch type,[7] palmar,[8–10] photo-distributed,[11–13] and pustular GA.[14] The lesions of GA are usually asymptomatic but can be pruritic, and were reported as painful in one case series of four patients with palmar GA.[10]

Figure 1.

a Localized granuloma annulare (GA) to hands only. b Classic annular lesion of GA

Figure 2.

a Generalized annular granuloma annulare (GA). b Similar annular lesions to that of localized GA

Figure 3.

a Generalized disseminated granuloma annulare. b Classic papular lesions of disseminated variant

Figure 4.

a Atypical generalized granuloma annulare. b Polymorphic morphology seen in atypical variant