Granuloma annulare is a benign granulomatous skin disorder of unknown cause.
Spontaneous resolution within 2 years is usual for the classic localized form although there may be recurrence. Generalized granuloma annulare often has a more prolonged course. Subcutaneous nodules are seen mainly in children and regress with time. Less common variants include the perforating and patch forms.
Patient and/or parent education with advice to await spontaneous remission is recommended in the majority of cases, particularly for localized disease in children. Active treatment may be required for lesions which are symptomatic, extensive, persistent, or particularly unsightly.
There is no ideal evidence-based treatment for granuloma annulare. Reflecting this unmet need, many potential therapeutic approaches have been published in the literature.1,2 Reports of benefit are largely based on case reports and small case series without controls. Treatment often proves disappointing and benefit can be difficult to assess in a condition that remits spontaneously. Potential adverse effects, risk/benefit evaluation, and cost must be considered before initiating a trial of therapy. See Table 15-1.
Table 15-1Granuloma Annulare Treatment Table ||Download (.pdf) Table 15-1 Granuloma Annulare Treatment Table
|MEDICATION NAME ||INDICATION ||MECHANISM OF ACTION ||DOSING ||ADVERSE EFFECTS ||SUGGESTED MONITORING ||LEVEL OF EVIDENCE (REFERENCE) |
|Topical Therapy |
|Clobetasol propionate (or alternative topical corticosteroid) ||Localized GA ||Anti-inflammatory ||0.05% cream; apply BID for 2-4 wk ||Skin atrophy, striae ||Cutaneous examination ||IV3 |
|Tacrolimus ||All forms ||Anti-inflammatory ||0.1% ointment; apply BID ||Skin irritation ||None ||IV4 |
|Pimecrolimus ||All forms ||Anti-inflammatory ||1% cream; apply BID ||Skin irritation ||None ||IV5 |
|Tofacitinib ||Localized GA ||Anti-inflammatory ||2% ointment; apply BID ||Potential skin irritation ||None ||IV6,7 |
|Imiquimod ||Localized GA ||Unknown ||5% cream; apply QD for 6-12 wk ||Skin irritation ||None ||IV8 |
|Systemic Therapy |
|Hydroxychloroquine ||Generalized GA ||Anti-inflammatory ||200-400 mg QD oral (5 mg/kg/d; max 400 mg QD) ||Pigmentation; GI upset, retinal toxicity ||Annual eye evaluation ||IV9,10 |
|Doxycycline ||Generalized GA ||Anti-inflammatory ||100 mg QD ||Contraindicated in pregnancy or age < 8 yo; pigmentation, esophagitis ||None ||IV11 |
|Rifampin/ofloxacin/minocycline ||Generalized GA ||Anti-inflammatory ||Rifampin 600 mg, ofloxacin 400 mg, minocycline 100 mg, once monthly for 3-6 mo ||Gastrointestinal effects, jaundice, red colored urine (rifampin); autoimmune hepatitis/lupus like syndrome, headache, drug reaction with eosinophilia and systemic symptoms/DRESS (minocycline) ||Baseline CBC and liver enzymes; repeat monthly ||IV12,13 |
|Dapsone ||Generalized GA ||Anti-inflammatory ||25-200 mg/d (low dose initially) ||Hemolytic anemia, methemoglobinemia, myelosuppression, severe drug hypersensitivity reactions (eg, drug reaction with eosinophilia and systemic symptoms/DRESS), peripheral neuropathy || |
G6PD assay prior to treatment (contraindicated in G6PD deficiency).
Monitor CBC, liver enzymes prior to treatment, in 1 wk and then monthly for 3 mo
|Isotretinoin ||Generalized GA ||Unknown ||0.5-1 mg/kg QD ||Teratogenic, skin and mucosal dryness, raised lipids, and liver enzymes |
CBC, CMP, lipid panel, pregnancy testing prior to treatment.
Monthly pregnancy ...