Successful treatment of disseminated granuloma annulare in a 10-year-old patient with 5% imiquimod cream

Granuloma annulare (GA) is a chronic skin condition in which smooth annular plaques are observed [1].The condition is characterized by asymptomatic, erythematous papules, usually arranged symmetrically in rings of 1–5 cm or more in diameter [2]. They are usually located on the extremities, trunk and neck. GA has different clinical variants, namely, localized, generalized or disseminated, subcutaneous and perforating. Contrary to the localized form, lesions may persist up to 3 years or longer in a disseminated type. The localized annular and subcutaneous forms are common in children and young adults, whereas the generalized variant is more common among adults.
We present the case of a 10-year-old female patient who was admitted to our Clinic with disseminated papular lesions. For one and a half year, spots on the wrists, feet, knees, and elbows were observed. A few weeks before new foci on the thighs, calves and trunk appeared. Until now, she was treated topically with clobetasol, with no beneficial outcome. The patient had no accompanying diseases and no family burden towards cancer or skin diseases. She was vaccinated according to the vaccination calendar. At admission, the following were observed: scattered papules on the skin of the upper and lower extremities and larger papular-macular foci of the pale pink colour in the flexed areas of ​​the wrists, dorsum of the feet, extension area of the knees and elbows and around the skin of the back. Two full-thickness skin biopsies were taken for histopathological examination. The results have revealed a focus of the interstitial infiltration of histiocytes (granulomatous inflammation) with areas of collagen degeneration in which the mucin masses were concentrated. Moreover, perivascular clustering of small lymphocytes could be observed. Due to the typical clinical picture and histopathological examination’s result, the patient was diagnosed with GA.
Dermatological literature provides little information about the treatment of GA. Most of the information is derived from individual case reports and small studies with no control groups. In most cases of GA, no treatment is required because the patches disappear by themselves in a few months, leaving no trace [3]. However, systemic therapy is crucial for the disseminated type of GA as lesions can persist for years and seldom could be complicated with nerve involvement, resulting in a granulomatous inflammation of cutaneous nerves. Treatment...


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