Itching for an Answer: Managing a Recurrent Evolving Annular Rash in a Teen Girl

Abstract

A 13-year-old female with a history of atopy presented with a recurrent and worsening skin rash for 2 months (Figure 1). Around age 3 years, she developed a scaly, pink patch in the shape of a heart on her left dorsal foot. She was treated for tinea corporis with over-the-counter topical antifungal cream and hydrocortisone without response. A presumptive diagnosis of granuloma annulare was subsequently made and she was treated with desoximetasone 0.25% cream and halobetasol propionate 0.05% ointment for 6 months with no improvement. Parents stopped the topical steroids and the lesion resolved on its own several months later. It never itched or caused pain; it did not bother her. Over the next several years, the skin underneath the previous site became thicker and "lumpy." Examination at seven years old revealed a 1.5 cm subtle soft mobile subcutaneous nodule on the left dorsal foot. The lesion remained relatively unchanged until 2 months prior to presentation when she developed new slightly hyperpigmented "lumps" on her left foot. She described it as mildly pruritic. Although not painful, it was uncomfortable especially when wearing shoes and playing sports. Examination revealed multiple slightly violaceous soft mobile subcutaneous nodules extending down the left foot and persistence of the prior lesion.What are the causes of annular skin lesions in the pediatric population and how to treat them? Discussion: Annular lesions acquire their name from the Greek annulus, meaning "ring." These lesions characteristically manifest as circles of erythematous or otherwise discolored skin surrounding centers of normal or abnormal epidermis.