A Monocentric, Retrospective Analysis of 61 Patients with Generalized Granuloma Annulare

Abstract

Background: Granuloma annulare is a chronic noninfectious granulomatous skin condition with variable clinical presentations. Generalized granuloma annulare, defined as widespread disease with >10 skin lesions, accounts for 15% of all cases. Numerous associated diseases have been controversially discussed, most importantly diabetes mellitus, dyslipidemia, thyroid disease, malignancy and systemic infections. Objectives: The objective of our study is to describe disease characteristics, treatment outcome and associated diseases in patients treated at the Department of Dermatology of the University Hospital Zurich during the last 20 years. Methods: The hospital database was searched for patients with generalized granuloma annulare in the last 20 years (January 1, 1998, to December 31, 2017). Overall, 61 patients, 14 males and 47 females, were included in our study. The mean age was 58 years at first consultation. The diagnosis was verified clinically and histologically. Results: Generalized granuloma annulare occurred at a mean age of 55 years, more commonly in females. Pruritus was absent in 51% of all patients. Metabolic diseases including diabetes mellitus, hypercholesterinemia and hypertriglyceridemia were present in 10.5, 8.2 and 4.9%, respectively. Thyroid disease was present in 9.8% and malignant disease in 23%, including colorectal cancer, lymphoproliferative disease, squamous cell carcinoma of the esophagus, basal cell carcinoma and gynecological malignancy. Therapy was initiated in 92%, while second- and third-line therapy was performed in 70 and 39%, respectively. Benefit during therapy (e.g., full and partial remission) was achieved in 39.3% during first-line, in 39.4% during second-line and in 33.8% during third-line treatment. Topical corticosteroids were the most commonly prescribed treatment, mostly leading to stable disease (46.6%). Combined full and partial remission occurred in a large proportion of patients receiving UVA1 (45%), PUVA (63.6%) and intralesional triamcinolone acetonide (100%). Conclusions: Generalized granuloma annulare is a mostly asymptomatic and benign disease with a strong tendency for treatment resistance. We suggest to screen all patients for dyslipidemia, thyroid disease and malignant disease. While randomized trials are needed, we suggest topical corticosteroids as the first-line treatment, intralesional triamcinolone acetonide for persistent solitary lesions and, if further treatment is needed, UVA1 or PUVA.

Granuloma Annulare: An Updated Review of Epidemiology, Pathogenesis, and Treatment Options

“…Another retrospective study of 49 generalized GA patients showed similar response rates, with topical corticosteroid treatment leading to stable disease in 46.6% of patients, partial remission in 19% of patients, complete remission in 10.3% of patients, and disease progression in 8.6% of patients. In the same study, of five other patients treated with intralesional triamcinolone, two achieved partial remission and three achieved total remission [ 59 ]. A 2021 retrospective study investigated the efficacy of topical corticosteroids alone, intralesional triamcinolone alone, and combination topical and intralesional corticosteroid therapy.…”

“…Megna et al reported complete clearance of disseminated GA in one patient with an 8-week course of HCQ 200 mg twice daily [ 65 ], and Xu et al reported a pediatric patient who experienced complete remission of disseminated GA after 6 months of treatment with HCQ 25 mg once daily [ 66 ]. In a retrospective review by Nordmann et al, of the five patients who were treated with HCQ, one patient achieved complete clearance, two achieved partial clearance, and one showed stable disease [ 59 ]. However, in the retrospective review conducted by Rubin and Rosenbach, only five of the 12 patients who were treated with HCQ showed improvement [ 58 ].…”

“…In another case series of five GA patients treated with UVA1, two experienced complete clearance, two experienced partial clearance, and one patient did not respond to treatment [ 84 ]. In the retrospective study by Nordmann et al, of the 20 patients receiving UVA1 therapy, three experienced full remission, six achieved partial remission, seven had stable disease, and one experienced disease progression [ 59 ].…”

A Review of the Dermatological Complications of Giant Cell Arteritis

“…In comparison to the localized form, it usually affects older patients, has a prolonged course of the disease, and has a worse response to conventional treatment. 56 , 57 Skin biopsies usually show degeneration of the elastic fibers with loss of peripheral microfibrils and abnormal elastic matrix along with the presence of granulomatous infiltrate. 58 Likewise, in GCA, disruption of the internal elastic lamina and the presence of granulomatous giant cell infiltrate are found in temporal biopsy samples.…”

Association of Nonalcoholic Hepatic Fibrosis with Body Composition in Female and Male Psoriasis Patients

“…Although historically methotrexate (MTX), one of the most used systemic antipsoriatic agents, has been linked with hepatotoxicity in psoriasis, more recent data suggests that metabolic syndrome (obesity, insulin resistance, hyperglycemia, and dyslipidemia) is the leading cause of NAFLD and fibrosis both in the general population and in psoriasis patients [ 18 ]. Although body composition differences, specifically, increased fat percentage has recently been reported as an independent risk factor for incident NAFLD [ 19 ], to date body composition has not been prospectively investigated in psoriasis in the context of liver fibrosis. Therefore, we undertook a study to assess the association of liver fibrosis with body composition factors in a population of severe psoriasis patients.…”