Granuloma Annulare  Information for adults

Although granuloma annulare can occur in people of any race and at any age, it is most commonly seen in children and young adults. Females are slightly more likely than males to develop granuloma annulare.

Granuloma annulare occurs most frequently over the joints or in areas that experience mild injury. The most common locations for granuloma annulare include:

• Backs of the hands and tops of the fingers
• Tops of the feet
• Around the elbows
• Around the knees

The lesions of granuloma annulare are usually found in the same areas on both sides of the body (symmetrically).

Granuloma annulare appears as small (1–3 mm), skin-colored or pink bumps. These bumps, which are smooth rather than scaly, may occur singly or in groups. Each bump may expand in size, leaving a shallow indentation in the center, which may be lighter or darker than your normal skin color. Alternatively, several small bumps may merge to form a ring, 1–5 cm in diameter. Healed lesions of granuloma annulare do not leave scars.

Granuloma annulare does not usually have any symptoms, though some individuals may experience itching.

Rarely, granuloma annulare may be widespread, called generalized granuloma annulare. Generalized granuloma annulare tends to appear in adults over 30 years old. The condition may consist of hundreds to thousands of 1–2 mm bumps that appear on the arms, legs, and upper trunk. These skin-colored or pink bumps may be quite itchy.

Because granuloma annulare does not usually have symptoms, it may go unnoticed for many months. If, however, the lesions are itchy, an over-the-counter cortisone cream may be helpful.

If you have bumps or ring-shaped lesions on your skin for more than several weeks, it is probably a good idea to have them evaluated by a dermatologist or by another health care provider who can distinguish them from conditions such as ringworm, insect bites, or even Lyme disease.

If the diagnosis of granuloma annulare is not obvious, the doctor may want to perform a skin biopsy. The procedure involves:

1. Numbing the skin with an injectable anesthetic.
2. Sampling a small piece of skin by using a flexible razor blade, a scalpel, or a tiny cookie cutter (called a "punch biopsy"). If a punch biopsy is taken, a stitch (suture) or two may be placed and will need to be removed 6–14 days later.
3. Having the skin sample examined under the microscope by a specially trained physician (dermatopathologist).

Once the diagnosis of granuloma annulare is confirmed, you and your physician may decide to not treat it. Up to 70% of cases of granuloma annulare go away by themselves (spontaneous resolution) within 2 years, even without treatment. However, up to 40% of people may experience a return of the lesions (recurrence), usually at the same site(s) of the original rash.

If the lesions of granuloma annulare are uncomfortable or unsightly, the physician may try one of the following:

• A prescription-strength steroid or cortisone cream
• Steroid injections directly into the lesions
• Freezing with liquid nitrogen (cryotherapy)
• Non-steroid topical anti-inflammatory creams such as tacrolimus or pimecrolimus
• Treatment with carbon dioxide laser

Generalized granuloma annulare is more stubborn, with fewer cases of spontaneous resolution and more recurrences. In addition, more aggressive medications may be used:

• Oral steroids, such as prednisone
• Oral retinoids, such as isotretinoin
• Ultraviolet light
• Other oral medications such as potassium iodide, dapsone, nicotinamide, pentoxifylline, hydroxychloroquine, or cyclosporine