Patch granuloma annulare: clinicopathological characteristics and response to phototherapy

Efficacy and Satisfaction of Low Doses UVA1 Phototherapy: A Spanish Experience from a Single Centre

Background: UVA1 phototherapy is a treatment used for multiple dermatological conditions. The optimal therapeutic regimens and dosing of UVA1 are a matter of debate. The dosages used vary widely between published studies and there are no evidence-based protocols that provide data on dosage, duration, or the role of maintenance therapy. The purpose of this study is to evaluate the experience in our medical center regarding treatment with UVA1, as well as the degree of patient satisfaction with the treatment according to their pathology. Methods: We present a retrospective evaluation of outcomes, treatment tolerability, and satisfaction in adult patients using a low dose of UVA1 phototherapy, administered in our dermatologic service between 2019 and 2022. Results: A total of 78 patients were treated with UVA1, of whom 46 patients (59%) were over 18 years old, completed treatment, and gave their consent. The overall objective clinical response rate was 91.30% (42/46), achieving a complete response in 17 (36.96%) patients, partial response in 25 (54.34%), and no response in 4 (8.70%). The complete response rates recorded were high in morphea, scleredema, or chronic hand eczema. In terms of the level of satisfaction objectively measured by TSQM-9 version 1.4, highlighting high scores obtained in mastocytosis, systemic sclerosis, morphea, scleredema, chronic hand eczema, or prurigo nodularis (over 65 points). Conclusions: We present a review of treatment with UVA1 phototherapy at low doses with good response in a wide variety of dermatological pathologies.

Light- and laser-based treatments for granuloma annulare: A systematic review

BACKGROUND

Granuloma annulare (GA) is challenging to treat, especially when generalized. A systematic review to support the use of light- and laser-based treatments for GA is lacking.

METHODS

We performed a systematic review by searching Cochrane, MEDLINE, and Embase. Title, abstract, full-text screening, and data extraction were done in duplicate. Quality appraisal was performed using the Joanna Briggs Institute critical appraisal tool for case series.

RESULTS

Thirty-one case series met the inclusion criteria, representing a total of 336 patients. Overall, psoralen ultraviolet light A (PUVA) showed the greatest frequency of cases with complete response (59%, n = 77/131), followed by photodynamic therapy (PDT) (52%, n = 13/25), ultraviolet light B (UVB)/narrowband UVB (nbUVB)/excimer laser (40%, n = 19/47), UVA1 (31%, n = 27/86), and lasers (29%, n = 8/28). Overall across treatment modalities, higher response rates were seen in localized GA compared to generalized GA.

CONCLUSIONS

The body of evidence for light- and laser-based treatment of GA is sparse. Our results suggest that PUVA has a high clearance rate for GA but its use may be limited by concerns of carcinogenesis. Although PDT has the second highest clearance rate, adverse effects, small sample sizes, impractical treatment delivery (especially with generalized disease), and long-term concerns of carcinogenesis may limit its use. Although UVB/nbUVB/excimer laser appeared slightly less effective than other light therapies, we recommend UVB/nbUVB/excimer laser therapy as a first-line treatment for patients with generalized GA given wider availability and a favorable long-term safety profile.

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

Granuloma annulare (GA) is an inflammatory granulomatous skin disease that can be localized (localized GA) or disseminated (generalized GA), with patch, perforating, and subcutaneous subtypes being less common variants of this benign condition. Recently, new research has emerged that further elucidates GA epidemiology and etiopathogenesis; importantly, new therapeutic options for GA have also been described, although there remains a paucity of randomized controlled studies. In this review, we summarize recent updates on GA epidemiology and etiopathogenesis and offer an updated review of the therapeutic options for GA currently reported in the literature. We hope that the current review galvanizes randomized controlled studies that will in turn help lead to the recommendation of evidence-based treatments for GA.

Generalized granuloma annulare in a case of breast cancer: A case report and review of the literature

Generalized granuloma annulare can be associated with breast cancer. Atypical granuloma annulare especially in older patients should alert physicians to the possibility of an occult malignancy.

Management of a Unique Presentation of a Common Dermatologic Condition

CONTEXT

Skin rashes are a common complaint seen in the primary care setting. There are many dermatologic conditions which a primary care provider (PCP) should be able to recognize and manage. One such condition is granuloma annulare (GA), which commonly presents as smooth, annular plaques on the trunk and/or extremities. Rashes like GA rarely present as unique variants and may be difficult for PCPs to determine from patient history and physical exam alone. Patch granuloma annulare (patch GA) is an example that may clinically mimic a cutaneous lymphoma known as mycosis fungoides (MF). PCPs should ideally be able to recognize the utility of performing a skin biopsy and/or referring the patient to a dermatologist when history and physical exam alone are insufficient. The histologic findings of skin biopsies often become essential in establishing a proper diagnosis and guiding patient management in unique dermatologic variants.

EXAMPLE CASE

The patient in this clinical practice report is a Caucasian female in her late 60s who presented to a dermatology clinic with a two-year history of a worsening widespread eruption on her trunk and extremities. She had been evaluated previously by her PCP about 4 months prior and, without obtaining skin biopsies, treated her with a medium potency topical corticosteroid cream. The eruption had spread over her hips, buttocks, back, thighs, wrists, and elbows. Multiple skin biopsies of affected sites were taken by the second author and revealed findings consistent with patch GA. The patient was started on topical betamethasone dipropionate 0.05% ointment twice daily and noted marked improvement of her symptoms.

CONCLUSIONS

Although GA is a benign condition of the skin that may be readily detected by PCPs, skin biopsies may be necessary to establish a proper diagnosis when this condition presents as a unique variant (e.g., patch GA). Therapy for patch GA often begins with a trial of high-potency topical steroid therapy in combination with ultraviolet light exposure, depending on disease severity and patient preference. Early evaluation with a skin biopsy by her PCP or an earlier referral to a dermatologist to have skin biopsies performed likely would have helped establish a prompter diagnosis and treatment plan for this patient.

Patch-type granuloma annulare: An institution-based study of 23 cases

BACKGROUND

Granuloma annulare (GA) is a skin disorder of uncertain etiology. Patch (type) GA is an uncommon variant of GA with a paucity of data characterizing it. We describe the features of 23 cases of patch GA.

METHODS

The archives of dermatopathology were searched for cases of patch GA. The clinical history and morphology for each patient were reviewed. Only cases with patch clinical morphology were included. The clinical and histopathologic features were assessed including the pattern of granulomatous inflammation and presence of other inflammatory cell types.

RESULTS

Most patients were female (19/23) with erythematous patches on the trunk and proximal extremities. The most common clinical differential diagnosis included mycosis fungoides (MF), morphea and contact dermatitis. Dyslipidemia was the most common comorbidity (30%), followed by diabetes (15%) and hypertension (15%). Histopathologic features included interstitial lymphocytes and histiocytes with dermal mucin. Two cases showed focal palisaded granulomas. Eosinophils and plasma cells were present in 1/3 of cases.

CONCLUSION

Patch GA is an uncommon GA variant with an interstitial granulomatous histopathologic pattern that predominantly affects women over 50. It can mimic interstitial MF and early morphea both clinically and histopathologically. Awareness of this GA variant can help prevent misdiagnosis and inappropriate treatment for these patients.