Generalized and patch granuloma annulare in a patient with psoriasis and multiple sclerosis after treatment with fingolimod

Granuloma annulare is an inflammatory cutaneous disorder which may present with localized, generalized, patch, perforating and subcutaneous forms. Granuloma annulare has been associated with diabetes mellitus, hyperlipidemia, malignancy, bacterial and viral infections. In addition, various medications such as tumor necrosis factor-a (TNF-a) inhibitors, allopurinol, amlodipine, paroxetine and tocilizumab have been implicated in the development of granuloma annulare. It has been suggested that activation of T helper (Th) 1 and the Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathways might play a role in the etiopathogenesis of granuloma annulare. However, the pathogenesis of drug-induced granuloma annulare has not been clearly understood yet [1]. Hereby, we report a 32-year-old Caucasian female patient with psoriasis and multiple sclerosis who developed both generalized and patch granuloma annulare at the same time 2 months after the initiation of oral fingolimod for the treatment of multiple sclerosis.
A 32-year-old female patient was admitted with a 10-month history of asymptomatic erythematous macules and plaques on the trunk and extremities. The lesions first appeared in the inframammary fold and then increased in size and number gradually. The patient stated that the lesions occurred 2 months after the initiation of oral fingolimod 0.5 mg/day for the treatment of multiple sclerosis. The patient was previously treated with 0.1% mometasone furoate and 1% terbinafine hydrochloride cream twice daily for 8 weeks. However, no clinical response was achieved. Fingolimod was discontinued 2 months ago due to skin lesions. The past medical history was remarkable for multiple sclerosis, psoriasis and asthma. The patient revealed that she was diagnosed with psoriasis vulgaris at the age of 9. She was treated with topical medications with complete clearance. However, she reported a psoriasis plaque that recently developed on her arm. The family history was remarkable for psoriasis in her sister. Dermatological examination revealed erythematous round-shaped macules and plaques with distinct borders on the breasts, inframammary fold and intermammary region. In addition, erythematous macules and slightly elevated plaques were detected on the right arm, dorsum of the right hand, leg, feet and abdominal region. On the other hand, the erythematous and squamous plaque which was detected on the extensor surface of the right forearm...


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