Disseminated Granuloma Annulare

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Granuloma annulare (GA) is an idiopathic disorder that occurs in both children and adults. The individual lesions are pink to skin-colored papules and they often coalesce to form rings and arcs, hence the term annulare. In the classic form of the disease, lesions are found predominantly on the distal extremities. One theory advanced to explain the distribution of GA is that it represents an unusual granulomatous reaction to trauma or arthropod bites. Occasionally, a patient will have generalized or widespread lesions of GA (see Fig. 3) and this is the form of GA associated with diabetes mellitus. In 1 series of 100 patients with generalized GA, 21% were shown to have diabetes (36).

Treatment of GA overlaps significantly with that of NLD (as outlined earlier). For example, initial therapy, especially for localized disease, consists of topical cortico-steroids (including class I) with or without occlusion and intralesional corticosteroids (24). For the generalized form of GA, systemic therapies are often required, as topical agents and intralesional injections can prove impractical. When the lesions are inflammatory, high-dose oral niacinamide (500 mg tid) is usually our initial treatment of choice (37). If this medication fails and the patient is still concerned about the appearance of the cutaneous eruption, oral PUVA can be prescribed (38). There are also scattered reports of the use of oral retinoids, dapsone, clofazamine, antimalarials, pentoxifylline, and cyclosporine for the treatment of widespread GA (23,24).

Disseminated Granuloma Annulare Images
Fig. 4. Eruptive xanthomas on the lower thighs and knees in a patient with poorly controlled diabetes and hypertriglyceridemia. The papules are discrete and firm to palpation.

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