Indian Journal of Dermatopathology and Diagnostic Dermatology

: 2019  |  Volume : 6  |  Issue : 1  |  Page : 48--50

Disseminated subcutaneous granuloma annulare in adult

Bhavana Ravindra Doshi, Vijaya V Sajjan, BS Manjunathswamy 
 Department of Dermatology, KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka, India

Correspondence Address:
Dr. Bhavana Ravindra Doshi
Department of Dermatology, KLE Academy of Higher Education and Research's JN Medical College, Belagavi, Karnataka


Granuloma annulare (GA) is a common benign inflammatory dermatosis of unknown cause. The subcutaneous form of GA also known as pseudorheumatoid nodule is a relatively uncommon entity, more so in the adult age. We came across a middle-aged female with multiple or disseminated lesions of subcutaneous GA located at an unusual location such as the volar aspect of palms beside the relatively common sites such as elbow and forearm.

How to cite this article:
Doshi BR, Sajjan VV, Manjunathswamy B S. Disseminated subcutaneous granuloma annulare in adult.Indian J Dermatopathol Diagn Dermatol 2019;6:48-50

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Doshi BR, Sajjan VV, Manjunathswamy B S. Disseminated subcutaneous granuloma annulare in adult. Indian J Dermatopathol Diagn Dermatol [serial online] 2019 [cited 2019 Aug 22 ];6:48-50
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Subcutaneous GA is a rare benign inflammatory entity characterized by nodular skin colored to erythematous asymptomatic lesions clinically and palisading histiocytic granulomas with necrobiosis and mucin histologically. Multiple subcutaneous GA is rare in adulthood; which we wish to report along with a brief review of its histopathologic differential diagnosis 1>.

 Case Report

A 55-year-old female came to our outpatient department with a 3 years' history of asymptomatic skin colored to slightly violaceous to yellow-colored elevated skin lesions over the extensor aspect of the forearm, elbows, wrist, interphalangeal joint, and palms [Figure 1]a, [Figure 1]b, [Figure 1]c. She had no underlying medical condition at the time of presentation. The patient denied a history of having any joint pains, any intake of drugs before the onset of these lesions. Clinical examination revealed several round-to-oval, deep subcutaneous, indurated, asymptomatic, discrete pigmented lesions ranging in diameter of 4 mm–1 cm. In view of the clinical presentation, a differential diagnosis of eruptive xanthomas, rheumatoid nodule, and granuloma annulare (GA) was kept.{Figure 1}

Hematologic and biochemical tests for blood sugars revealed derangement in the sugar profile which revealed random sugar – 322/mg/dl, fasting sugar levels – 226 mg/dl, HbA1c – 10.2 along with and lipid profile showing mildly deranged levels of serum cholesterol – 225 mg/dl, and serum triglyceride – 190 mg/dl. Serological tests for rheumatoid factor, ANCA, ANA, and anti-CCP antibody were negative.

Biopsy from wrist lesion on hematoxylin and eosin stain revealed the presence of well circumscribed palisaded histiocytic granulomas located in the mid and lower dermis. Center of these granulomas showed changes of necrobiosis in the form of degenerated bundles of collagen in center surrounded by palisade of histiocytes, fibroblasts, multinucleate giant cells, occasional neutrophils, and nuclear dust along with stingy faintly blue deposition within the center of palisaded granulomas [Figure 2]a, [Figure 2]b ,[Figure 2]c, [Figure 2]d. The biopsy section was negative for tuberculous bacilli (Ziehl–Neelsen stain) and fungal elements (Gomori Methenamine silver stains and Periodic acid–Schiff) and stained positive for mucin in the center of granuloma on Alcian blue staining [Figure 2]e. In view of the above findings, a diagnosis of subcutaneous GA was reached. Subsequently, two more biopsies were done from the forearm which too revealed similar histology.{Figure 2}

The patient was started on tablet rosuvastatin 40 mg daily and metformin 1 gm dose along with tablet glimepiride 2 mg/day along with capsule isotretinoin 30 mg/day. The patient reported about 50% reduction in the size of lesions with near flattening of the lesions over the elbow region in the span of 1 month.


The cause of subcutaneous GA remains unknown. Some mechanisms have been proposed such as physical trauma, infections (streptococci, tuberculosis, Epstein–Barr virus, and herpes zoster), immunizations, bug bites, diabetes mellitus, and alterations in the cell-mediated immune responses.[1]

Literature review shows that the majority of pediatric and adult patients with subcutaneous granuloma annulare (SGA) have an unremarkable medical history.[2] The histopathology shows an infiltrate in the deep dermis and/or hypodermis of granulomas predominantly formed by palisaded histiocytes around a central region of degenerating collagen fibers (necrobiosis) and abundant mucin, best seen under alcian blue staining.[3] This is one of the examples of “blue granulomas” on light microscopy. Deposition of acellular substances such as mucin or neutrophils with nuclear dust renders a bluish hue to the granulomas. These “blue granulomas” can also be observed in Wegener's granulomatosis, palisaded and neutrophilic granulomatous dermatitis, rheumatoid vasculitis, and epithelioid sarcoma.[3],[4]

We are reporting a middle-aged patient with multiple or disseminated nodules of SGA over relatively less common site such as volar aspect of the palm. Detecting the characteristic histopathologic features of SGA were essential to differentiate the lesion from other similar lesions such as rheumatoid nodule (red granuloma), necrobiosis lipoidica (red granuloma), and palisaded and granulomatous neutrophilic dermatoses (blue granuloma). The differentiating features between these are highlighted in [Table 1].[4],[5] The SGA nodules usually are slowly growing and cause little discomfort which may delay the medical consultation.[6] However, sometimes, SGA may show a rapid growth that could be alarming to the patient and requires an extensive differential diagnosis.[7] As the majority of the SGA present on the extensor aspect of the limbs,[8] the presentation of the SGA in our patient on the palmer side of the fingers and volar aspect of palm is considered a rare presentation.[9]{Table 1}

To conclude, we are reporting a rare presentation of SGA with disseminated lesions including the involvement of the palmer side of the fingers, which responded well to isotretinoin[10] due to its proliferative and inhibitory effects on collagen synthesis in combination with the immunomodulatory effect of rosuvastatin.[11] SGA should be considered by a dermatologist in the differential diagnosis of subcutaneous nodules even in the absence of concomitant systemic disease and with rare presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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