|Year : 2021 | Volume
| Issue : 2 | Page : 220-222
Giant subcutaneous granuloma annulare
MR Harish, BM Shashikumar, Priyanka R Magod, Deepadarshan K Gowda
Department of Dermatology, Mandya Institute of Medical Sciences, Mandya, Karnataka, India
|Date of Submission||02-Mar-2020|
|Date of Decision||13-Jul-2020|
|Date of Acceptance||11-Sep-2020|
|Date of Web Publication||26-Aug-2021|
B M Shashikumar
OPD Room No. 13, RDL First Floor, Department of Dermatology, Mandya Institute of Medical Sciences, Nehrunagar, Mandya - 571 401, Karnataka
Source of Support: None, Conflict of Interest: None
Subcutaneous granuloma annulare is an uncommon, benign self-limiting cutaneous disease, almost exclusively seen in young children. We report a case of 31-year-old male patient, presented with asymptomatic firm plaques over the left lateral malleoli and dorsum of the feet. Histopathological examination was done to confirm the diagnosis and the lesions responded well to monthly doses of the combination of rifampicin, ofloxacin, minocycline (ROM) therapy and intralesional steroid therapy. This case is reported for its unusual presentation of very large plaque in an adult male and its resolution after combined ROM and intralesional steroid therapy.
Keywords: Intralesional therapy, rifampicin, ofloxacin, minocycline therapy, subcutaneous granuloma annulare
|How to cite this article:|
Harish M R, Shashikumar B M, Magod PR, Gowda DK. Giant subcutaneous granuloma annulare. Clin Dermatol Rev 2021;5:220-2
| Introduction|| |
Subcutaneous granuloma annulare (SGA) is a rare type of granuloma annulare. It predominantly affects the children aged between 2 and 5 years. There is a slight female preponderance with a female-to-male ratio of 2:1. The prevalence is unknown. SGA is characterized by firm asymptomatic nodules in the deep subcutaneous tissue that may be associated with intradermal lesions, with individual lesions measuring from 6 mm to 3.5 cm in diameter.
| Case Report|| |
A 27-year-old male presented with asymptomatic hyperpigmented papule over the lateral aspect of the ankle for 1-year duration. It slowly progressed in size and number; the largest plaque measuring about 10 cm × 6 cm was present over the left lateral malleoli extending up to the tendoachilles posteriorly, while other two lesions measuring about 4 cm × 3 cm and 3 cm × 2 cm were present over the dorsum of the left foot and ankle. Lesions were not associated with scaling, tenderness, or itching [Figure 1].
|Figure 1: (a-c) Pretreatment lesions present over the left ankle and foot|
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Clinical differential diagnosis of xanthoma, erythema elevatum diutinum (EED), and reticulohistiocytosis was considered keeping in account the common site of occurrence, that is, tendons, extensor surfaces, and dorsal aspects of the joints, and necrobiosis lipoidica was considered as the lesions showed well-demarcated smooth plaques with erythematous to violaceous raised, indurated, and irregular borders.
Histopathology of the lesion revealed a palisading granuloma in the mid and lower reticular dermis around foci of the mucin and fibrin deposition and with incomplete collagen degeneration [Figure 2]. This is in concordance with the diagnosis of SGA. Histology of xanthomas of the skin and tendons highlights the presence of foam cells. In EED, lipids and lipophages between collagen bundles, necrotizing granuloma, neutrophilic microabscesses in the tips of the dermal papilla, and bulla are prominent histopathological features. Reticulohistiocytosis displays a dermis filled with multinucleated giant cells with a pale, fine, granular, ground-glass eosinophilic cytoplasm whereas necrobiosis lipoidica demonstrates a layered inflammatory process and alternating zones of necrobiosis involving the full thickness of the dermis. Other blood investigations were normal.
|Figure 2: (a and b) Histopathological examination showing palisading granuloma (black arrow) composed of lymphocytes, histiocytes, and occasional giant cells in the mid and lower reticular dermis (a, H and E, ×10 and b, H and E, ×40)|
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The patient was started on monthly rifampicin, ofloxacin, minocycline (ROM) therapy (rifampicin 600 mg, ofloxacin 400 mg, and minocycline 100 mg) for 6 months. In addition, the patient was also given intralesional steroid (2.5 mg/ml) every fortnightly for 3 months. After 3 months, the patient showed complete clearance of the lesions leaving behind hyperpigmentation at the affected site [Figure 3].
|Figure 3: (a and b) Posttreatment resolution of the lesions leaving behind hyperpigmentation at the affected site|
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| Discussion|| |
Granuloma annulare was first described by Colcott Fox in 1895. Ziegler in 1941 was the first to note the presence of subcutaneous pseudorheumatoid nodules occurring concomitantly in a patient with localized granuloma annulare.
SGA has been given several names, such as pseudorheumatoid nodule, isolated subcutaneous nodule, subcutaneous palisading granuloma, and palisading granuloma nodosum.
The cause of SGA remains unknown. Some factors have been proposed such as physical trauma, infections (streptococci, tuberculosis, Epstein–Barr virus, and herpes zoster), vaccination, insect bites, diabetes mellitus, and altered cell-mediated immune response. They are prevalent on the anterior tibial plateau, ankles, dorsum of feet, buttocks, hands, scalp, and eyelids.,
Although the reports of spontaneous resolution of SGA have been reported, varied treatment modalities are being considered for early remissions, such as the high-potency topical corticosteroids such as clobetasol 0.05% twice a day, the intralesional corticosteroids, cryotherapy, laser therapy, electrocoagulation, PUVASOL, and topical imiquimod.
Shilpa et al. conducted a study on the efficacy of monthly pulsed ROM therapy in the management of granuloma annulare which showed complete resolution of lesions.
| Conclusion|| |
Due to infrequent occurrence of subcutaneous granuloma in adult males and unusually large size of the lesion mimicking xanthoma and its response to the combination of ROM and intralesional steroid therapy, this case is being reported.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]