Multiple Granuloma Annulare in a 2-year-old Child.

Granuloma annulare is a benign, self-limiting, inflammatory and granulomatous disease of unknown etiology occurring in both adults and children. An 18-month-old male child had multiple progressive annular plaques over the lower extremities. Clinical and histopathological features were consistent with granuloma annulare. Localized granuloma annulare is the most common form in children. We report a young child with multiple, progressive granuloma annulare over the lower extremities.

What was known?

Localized variant of granuloma annulare is common in childhood.

Introduction

Granuloma annulare (GA) was first described in 1895 by Colcott-Fox who reported an 11-year-old girl with a “ring eruption of the fingers.”[1] The condition is a benign, usually self-limited granulomatous disease of the dermis and subcutaneous tissue.[2] The term “granuloma annulare” was coined by Radcliff-Crocker in 1902.[3] Clinically, the condition is characterized by asymptomatic, flesh-colored or erythematous-brown papules, frequently arranged in a ring or annular pattern on the distal extremities.[4] It may be skin-colored erythematous or violaceous measuring 1-5 cm in diameter.[45] Several clinical variants of GA have been reported, namely localized, generalized or disseminated, targetoid, giant, subcutaneous and perforating GA.[6] We report an 18-month-old male child with multiple, progressive GA over the lower extremities.

Case Report

An 18-month-old male child presented with multiple annular lesions over lower extremities and buttocks. Initially it started as a small papule over the left thigh, substantially attaining the present size. Similar lesions appeared over the other sites. There was no history of fever, pain, drug intake or recent vaccination.

On examination, the child was afebrile without pallor, clubbing, cyanosis, icterus and lymphadenopathy. Height, weight, head circumference and vitals were normal. Immunization status was up-to-date. On cutaneous examination, closely set, skin-colored, firm, smooth papules 2-3 mm in size arranged in a ring-like fashion to form annular plaques measuring approximately 3 × 3 cm (eight lesions) were present over dorsal aspect of foot [Figures 1 and 2], both legs and buttocks. A clinical diagnosis of GA was made.

Figure 1

Granuloma annulare over the left foot

Figure 2

Granuloma annulare over the right ankle

Routine hematological, biochemical and urine examinations were normal. Venereal disease research laboratory test, human immunodeficiency virus 1 and 2, hepatitis surface antigen test were negative and a biopsy showed features consistent with GA.

Discussion

GA is a benign, relatively common cutaneous disease that classically presents as closely set, skin-colored, firm, smooth papules 2-3 mm in size arranged in a ring-like fashion to form annular lesions.[6] It often occurs symmetrically and lesions are typically asymptomatic. Most cases occur before the age of 30 years and it is approximately twice more common in females. It often favors sacral sites such as the dorsa of the hands, elbows and feet but involvement of the palms appears to be rare.[7]

It occurs in all age groups but is rare in infancy. The etiology of GA is unknown and the pathogenesis is poorly understood. Most cases are sporadic and occur in otherwise healthy children. Occasional familial cases are described with the occurrence in twins, siblings, and members of successive generations. Attempts to identify an associated HLA sub-type have yielded disparate results in different population groups.[8] Linear GA, a follicular pustular form and popular umbilicated lesions in children have also been described. More than one morphologic type may co-exist in the same patient. The localized annular and subcutaneous forms are common in children and young adults.[9] The generalized variant is more common in adults.

Generalized GA occurs in approximately 15% of patients with GA. The condition manifests as numerous (at least 10, often hundreds to thousands) small, asymptomatic, erythematous, violaceous, brown- or skin-colored papules.[10] Lesions are symmetrically distributed on the trunk, extremities, and neck. Our patient had multiple GA distributed over lower limbs asymmetrically.

Rarely, GA may be complicated by nerve involvement as a result of granulomatous inflammation surrounding cutaneous nerves and perineural infiltrates of histiocytes in the dermis. Localized GA usually resolves without scarring within 1 to 2 years.[11] The diagnosis is mainly clinical. The differential diagnoses of localized GA include tineacorporis, pityriasis rosea, pityriasis rotunda, erythema annulare centrifugum, nummular eczema, discoid lupus erythematosus, psoriasis, necrobiosis lipoidica, morphea, hypertrophic lichen planus and erythema chronicum migrans. Most cases are self-limited. Treatment options include topical or intralesional corticosteroids, imiquimod cream, topical calcineurin inhibitors (tacrolimus, pimecrolimus), cryotherapy, and pulsed dye laser.[12] Surgical removal may be done for subcutaneous GA. Systemic treatment may be required for generalized GA which is often resistant to treatment.

What is new?

Multiple progressive, generalized asymmetrical involvement, is an unusual feature.