Therapeutic difficulties in a patient with a generalized form of annular granuloma

Annular granuloma (Lat. granuloma annulare – GA) is a mild chronic inflammatory dermatosis, classified as a granulomatous skin disease. It is estimated that in the European population, its incidence is 0.1–0.4% [1]. The disease occurs mainly in young adults and children. However, it can appear at any age [1, 2]. Women suffer twice as often, especially in the 5th–6th decade of life [3]. Etiology of the disease has not been fully understood yet. The prevailing view today is that a delayed type immune response plays a key role in the pathogenesis of GA. Local damage to the dermis is believed to activate CD4+ T lymphocytes, secreting pro-inflammatory factors, e.g., interferon-g (INF-g), interleukin-2 (IL-2), tumor necrosis factor (TNF), which stimulate macrophages to produce extracellular matrix metalloproteases, which in turn results in the degradation of collagen fibers and the formation of granulomas visible in the histopathological picture [4, 5].
Typical clinical manifestation of GA involves hard, slightly raised lumps and nodules, with a smooth surface, flesh-colored or pale red in color, with a tendency to form ring-shaped foci that widen peripherally. Skin lesions are most often located on dorsal surfaces of hands and feet, but they can also occur in other locations. Usually they are not accompanied by subjective symptoms. However, itching of varying intensity may be present.
There are few publications in the dermatological literature on the methods of treating GA. Most of them are case studies. The choice of the appropriate therapy depends primarily on the clinical form of GA.
The most common type is the localized granuloma annulare (LGA), which occurs in about 75% of patients, more often in children and young adults [1]. In most LGA patients, skin lesions resolve spontaneously, usually within 2 years [1], therefore in some cases, especially in pediatric patients, a wait-and-see attitude may be considered [6]. In other cases, topical treatment with glucocorticosteroids, 0.1% tacrolimus or 5% imiquimod [7], and according to recent reports also 2% tofacitinib proves effective [8]. Another LGA therapeutic method involves intralesional injections of glucocorticosteroids or INF-g [9]. Good effects of cryotherapy [10], photodynamic therapy [11] and laser treatments [12] have also been reported.
The second most common type is generalized granuloma annulare (GGA), also referred to as disseminated granuloma annulare (DGA). It is found...


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