A 77-year-old woman with a history of type 2 diabetes mellitus, hypothyroidism, hypertension, and hyperlipidemia presented with a rash characterized by orange-yellow papules coalescing into erythematous annular plaques (Figure 1). The rash initially appeared on the dorsum of her hands about 20 years ago after a period of emotional stress, but subsequently spread to her trunk and both legs. She denied pruritus, tenderness, arthralgia, fever, chills, night sweats, or weight loss.
Widespread erythematous annular plaques on the patient’s legs.
A skin biopsy was obtained, which confirmed the diagnosis of granuloma annulare. Dapsone 25 mg daily and topical triamcinolone 0.1% resulted in temporary relief, but the rash recurred within the year. The patient was then started on methotrexate 15 mg weekly, and adalimumab 40 mg was added to treat generalized granuloma annulare, but the rash did not resolve. The rash ultimately improved slowly on resumption of dapsone with hydroxychloroquine 200 mg twice daily.
GRANULOMA ANNULARE
Granuloma annulare is an inflammatory granulomatous dermatologic condition with an unknown etiology that can be associated with diabetes (adjusted odds ratio 1.67), autoimmune conditions such as rheumatoid arthritis (adjusted odds ratio 2.05), thyroid disease, human immunodeficiency virus infection, and anxiety.1–3 In rare cases, it might suggest an underlying malignancy, especially in older patients.1,4 The localized variant accounts for about three-quarters of cases, and the generalized variant for 8% to 15%.1,5 Treatment response is poor.1
A skin biopsy is crucial for diagnosis and treatment because other skin lesions can look similar to granuloma annulare. Differential diagnoses include cutaneous sarcoidosis, which appears as nodules or plaques that can be verrucous; tinea corporis (ringworm) appears as a red, raised, scaly rash; necrobiosis lipoidica diabeticorum appears as shiny raised plaques; erythema annulare centrifugum has red patches or plaques; subacute cutaneous lupus has red scaly or ring-shaped lesions; and annular lichen planus appears as red-brown macules or papules with raised borders.1,6
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.
In this issue
Related Articles
Cited By...
- No citing articles found.