Granuloma anulare is a granulomatous skin disease associated with a ring-shaped papule formation, which particularly affects children, adolescents, as well as women. The skin disease is harmless and in many cases regresses without therapy.
What is granuloma anulare?
Granuloma anulare is the term used to describe benign, nodular papules (skin nodules or vesicles) that occur mainly on the hands and feet and primarily affect children and adolescents. A characteristic feature of granuloma anulare is the formation of a ring, which initially manifests itself in the form of white or skin-colored papules, which in the further course regress centrally with simultaneous spread to the periphery, so that a ring is formed. In this case, the skin of the ring is slightly raised and consists of several papules and nodules arranged in a row. Granuloma anulare may occur in single or multiple foci (especially in younger children). In addition, granuloma anulare is generally differentiated between the disseminated form, in which aggregated nodules and papules are distributed throughout the body, and the subcutaneous nodular form, which is primarily associated with nodules in the subcutis (especially on the head, buttocks, and legs).
Causes
The causes for the manifestation of granuloma anulare have not yet been elucidated. In previous studies, the condition was often associated with latent diabetes mellitus; however, recent research has not demonstrated a statistically significant correlation. Current studies suggest an association with impaired lipid metabolism, although it is unclear whether the metabolic disturbance is the consequence or the trigger of granuloma anulare. Likewise, cell-mediated or humoral overreactions of the immune system to as yet unknown agents and, in individual cases, trauma, excessive sun exposure, and insect bites are discussed as possible triggering factors. In addition, the disseminated form of granuloma anulare is associated with underlying HIV infection.
Symptoms, complaints, and signs
Granuloma anulare is a harmless condition characterized by an accumulation of small nodules on certain areas of the skin. The nodules do not cause itching or pain. Especially female children and adolescents can be affected by granuloma anulare. The ring-shaped spread of the nodules is typical. Within a few weeks, increasingly larger rings of papules form, while in the middle of the ring, the older nodules already begin to regress. However, the anular (ring-shaped) nodules persist for some time (months or even years) without treatment. However, they do not cause any discomfort. The backs of the hands and feet and the extensor sides of the toes, fingers, feet and hands are particularly affected. Ring-shaped groups of nodules are also sometimes observed on the forearms and lower legs. Less commonly, the papules also appear on the elbows, trunk, buttocks, or face. There are patients with single rings. However, in other affected individuals, multiple rings are present. Furthermore, some special forms of granuloma anulare are known. Sometimes scattered nodules appear on different parts of the body such as extremities and the entire upper body in adults. In some cases, a connection between HIV infection and this disseminated special form of granuloma anulare has been established. A subcutaneous nodular form is also sometimes found on the head, buttocks, and legs, in which the nodules are located under the unchanged skin.
Diagnosis and course
Granuloma anulare can usually be diagnosed on the basis of clinical symptoms, particularly the characteristic ring formation by the papules typical of the skin disease. In unclear or asymptomatic cases, the diagnosis is confirmed by a biopsy followed by histologic examination. Thus, histopathologically, a barely changed epidermis with necrobiotic areas showing variously degenerated collagen fibers in the corium (also dermis, dermis) can be seen under the microscope. Likewise, mucopolysaccharides, a strongly increased concentration of glycogen, epithelioid cellular granulomas as well as lymphocyte infiltrates can be detected in the dermis.Differentially, granuloma anulare should be distinguished from rheumatic nodules, necrobiosis lipoidica, and anular sarcoidosis. The course and prognosis are generally good in granuloma anulare, and spontaneous regression is seen in more than half of those affected within 2 years.
Complications
In most cases, granuloma anulare does not lead to any particular complications or discomfort. Even without treatment, the symptoms usually disappear again on their own, and the disease thereby heals on its own. Those affected suffer from papules, which can be distributed over the entire body. The skin in the affected regions is also red in color and may itch. In most cases, granuloma anulare occurs on the fingers, hands and feet and can lead to restrictions and discomfort in everyday life. It is not uncommon for this to cause pain when walking, which leads to restricted movement. If the pain also occurs in the form of pain at rest at night, this pain can lead to sleep complaints and thus to further psychological upsets. In general, granuloma anulare has a negative impact on the patient’s quality of life. In most cases, granuloma anulare does not require treatment and disappears on its own. Only in severe cases creams and ointments are used to alleviate the symptoms. There is usually no scarring and the patient’s life expectancy is not reduced by the disease.
When should you see a doctor?
Consultation with a doctor is necessary as soon as skin changes appear on the hands and feet. Especially in children and adolescents, possible abnormalities should be observed and presented to a doctor as soon as possible. If itching or inner restlessness occurs, this must be observed. If the affected areas are scratched open, sterile wound care must be applied. If this cannot be ensured to a sufficient degree with the patient’s own aids, the assistance of a physician or physician’s assistant should be sought. If circular poplars, ulcers, growths or nodules form on the skin, these abnormalities should be examined and clarified. If the complaints cause impairments of various kinds in everyday life, a doctor is needed. If locomotion cannot take place as usual, if one-sided physical strain sets in or if crooked posture occurs, a doctor must be consulted. There is a risk of permanent malfunction of the skeletal system. If the complaints in the hands or fingers impair daily activities such as writing, brushing teeth or holding objects, a doctor should be consulted. If, in addition to the physical symptoms, the affected person complains of sleep disturbances, malaise or appears with conspicuous behavior, it is advisable to contact a physician.
Treatment and therapy
Since granuloma anulare is generally harmless, does not cause any discomfort, and in many cases regresses spontaneously on its own, it does not need to be treated from a purely medical point of view. Especially in adult patients, where regression of granuloma anulare without therapy is rarely observed, therapeutic measures are often used for cosmetic reasons. The standard therapy is glucocorticoid or glucocorticoid steroid therapy applied with ointments or creams. In this context, effect-enhancing film dressings (so-called occlusion therapy), direct intralesional injections of the corticosteroid preparations into the affected skin areas, and icing with liquid nitrogen (cryotherapy) have proven effective. Although topical corticosteroids rapidly cause regression of granuloma anulare under occlusive conditions, given the high rate for spontaneous regression, potential side effects such as skin atrophy should be considered in the choice of therapy. If the disseminated form of granuloma anulare is present, systemic therapy with dapsone or isoniazid (isonicotinic acid hydrazide) or PUVA therapy may be indicated. In PUVA therapy, the affected skin areas are irradiated with UVA light in a special phototherapy booth. The therapy is carried out three to four times a week for a period of several months and usually causes a permanent disappearance of the granuloma anulare.In quite a few cases, minor interventions such as trial excisions or saline injections can lead to complete regression of granuloma anulare.
Outlook and prognosis
The prognosis of granuloma anulare is very favorable. The disease is considered by physicians and scientists to be potentially harmless and, under normal conditions, does not cause any severe impairment that results in weakening of health. Complications or diseases in the further course of life are also not to be expected. Normally, the irregularities of the skin appearance disappear within a few weeks without any external influence or the administration of medication. Medical care is not required for this disease in most patients. The changes in skin appearance can cause irritation and emotional discomfort in the affected person due to the visual blemish. On a physical level, the condition does not trigger concern or a need for action from a medical perspective. It is regarded as a temporary phenomenon that may need to be examined. When visiting a doctor, the focus is on ruling out other skin diseases. It must be clarified that the skin changes can be assigned to granuloma anulare and that no serious disorders are present. If psychological problems develop due to the visual irregularities, work should be done with a therapist to improve health. There are other issues present in the affected person that contribute to the deterioration of well-being and should be treated. Their prognosis should be considered on an individual basis.
Prevention
Because the causes of granuloma anulare have not yet been determined, the skin disease cannot be prevented.
Aftercare
In the case of granuloma anulare, there are usually no aftercare options available to the affected person. However, these are also not necessary, since this disease is a relatively mild and harmless disease, which in many cases also disappears on its own. Medical treatment is usually only necessary if the granuloma anulare does not heal on its own. In general, the person affected by granuloma anulare should observe a high standard of hygiene to prevent the disease from spreading. If the disease does not disappear on its own, creams or ointments can also be used to relieve the symptoms. In this case, regular application should be ensured. Even after the symptoms have disappeared, the creams should continue to be used for a few days in order to limit the discomfort completely. However, in severe cases, treatments by a doctor are necessary. The disease does not negatively affect the life expectancy of the affected person. If granuloma anulare occurs frequently, the reason for its occurrence must be identified in order to avoid the disease. In case of itching, the affected person should not scratch the skin to prevent the formation of scars.
This is what you can do yourself
In many cases, granuloma anulare does not need to be treated. If it does not present with severe symptoms or complications, treatment can be omitted, and the symptoms often disappear on their own. Usually, the patient has several self-help options available to limit the discomfort of the condition. The use of creams and ointments has a very positive effect on the symptoms of the disease and can limit them considerably. Especially the itching can be eliminated with soothing creams, which often also cool and thus soothe the skin. Especially in children, it must be pointed out that constant scratching only aggravates the symptoms and can lead to the formation of scars. Since scratching should therefore be avoided in any case. In the case of inferiority complexes or reduced self-esteem, discussions with other sufferers or with a psychologist often help. As a rule, a conversation with one’s own partner also has a very positive effect on the disease. Granuloma anulare does not have a negative effect on the patient’s life expectancy.
