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8-year-old girl with annular, pink plaques on the feet
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An 8-year-old girl presents to your office with a rash unresponsive to therapy. She first noticed pink papules appearing on the feet 10 months ago. They gradually enlarged and developed central clearing. She denies pruritus, pain and scaling. She has been treated for tinea corporis for 9 months with topical creams, first with over-the-counter terbinafine 1% cream and then prescription ketoconazole 2% cream twice daily to the affected areas. The lesions continued to enlarge and none cleared; thus, she was subsequently treated with griseofulvin for 1 month without improvement.
Physical examination reveals 1 cm to 3 cm annular, pink to violaceous plaques with relative central sparing on the feet (Figures 1 and 2). On palpation, 2 mm to 3 mm papules are felt at the periphery of the plaques.
Carrie Coughlin
Marissa J. Perman
Can you spot the rash?
Diagnosis: Granuloma annulare
Granuloma annulare is a common skin disease with unknown etiology. It occurs in children and adults. The classic form of granuloma annulare involves smooth, annular plaques with centrifugal spread that are self-limited and tend to resolve within a few years; location on the dorsum of the hands and feet is common. There are many subtypes of granuloma annulare beyond the typical localized form: popular; disseminated/generalized; subcutaneous/deep; and perforating. The rash typically occurs in isolation, but, as shown in a recent study of adults, patients with the disseminated form are more likely to have dyslipidemia than patients with localized granuloma annulare and patients without granuloma annulare. Association of granuloma annulare with diabetes mellitus has also been explored, with mixed results, and is mainly limited to adults.
The differential diagnosis for localized plaque-type granuloma annulare includes tinea corporis, subacute cutaneous lupus, tumid lupus, erythema annulare centrifugum, morphea and necrobiosis lipoidica. The lack of scale differentiates granuloma annulare from tinea corporis, subacute cutaneous lupus and erythema annulare centrifugum. The central clearing distinguishes granuloma annulare from tumid lupus; location can also help distinguish the two, as tumid lupus is typically seen on the face and chest.
Figures 1 and 2: Pink annular plaques on the dorsum of the feet
Images: Perman MJ
The papular periphery of the lesions and lack of atrophy differentiates granuloma annulare from morphea. Necrobiosis lipoidica generally presents in adults and tends to be more yellow. Papular granuloma annulare can mimic papular forms of atopic dermatitis and urticaria. Granuloma annulare can be pruritic but is typically less pruritic than either of these entities. Deep granuloma annulare is most commonly located on the anterior lower legs. Thus, it can mimic erythema nodosum; however, erythema nodosum is generally tender. Deep granuloma annulare is also seen on the scalp and other parts of the body. It can be differentiated from a pilar cyst by palpation (lack of clear circumscription and not as freely mobile) and from an enlarged lymph node by location and lack of the same degree of mobility.
Many regimens are used in the treatment of granuloma annulare. As the disease is typically self-limited and heals without scarring, no treatment is required. However, some patients request treatment to improve the appearance of the lesions.
For the classic plaque type of granuloma annulare, as seen in our patient, topical steroids may be used as first-line treatment. Potent or superpotent formulations are needed. For classic and deep granuloma annulare, intralesional steroids may be attempted, but there is a risk of atrophy, as with any steroid injection. Otherwise, light therapy or other treatments used for generalized granuloma annulare can be considered in patients with more extensive involvement.
Physicians should be aware of this diagnosis to provide reassurance to patients and their parents. Moreover, as the primary differential diagnosis is tinea corporis, unnecessary courses of oral antifungal treatment can be avoided and patients can be informed their rash is not contagious and does not require limitations for participation in sports.
Wu W. Arch Dermatol. 2012;148:1131-1136.
Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia.
Disclosure: Coughlin and Perman report no relevant financial disclosures.