Granuloma annulare in a young patient: An unusual presentation

Vinicius Clementino Falcao; Elvira Barbosa Abreu; Julia Valdemarin Burnier; Miguel Noel Burnier

doi:10.4103/PAJO.PAJO_14_19

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CASE REPORT

Year : 2019 | Volume : 1 | Issue : 1 | Page : 10

Granuloma annulare in a young patient: An unusual presentation

Vinicius Clementino Falcao¹, Elvira Barbosa Abreu¹, Julia Valdemarin Burnier², Miguel Noel Burnier¹
¹ Department of Ophthalmology, Penido Burnier Institute, Campinas, SP, Brazil; Ocular Pathology and Translational Research Laboratory, MUHC-McGill University, Montreal, Canada
² Ocular Pathology and Translational Research Laboratory, MUHC-McGill University, Montreal, Canada

Date of Submission	11-Jul-2019
Date of Acceptance	05-Aug-2019
Date of Web Publication	07-Oct-2019

Correspondence Address:
Dr. Miguel Noel Burnier
McGill University Ocular Pathology and Translational Research Laboratory, 1001 Boulevard Decarie, Block E, E02-6217, Montreal, Quebec H4a3J1

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PAJO.PAJO_14_19

Abstract

Here, we report the case of a 16-year-old patient with lesions on the upper eyelids, which were diagnosed as granuloma annulare. This is an uncommon site of presentation of this lesion type, which is more commonly found on the extremities such as the hands, ankles, and trunk. Excisional biopsy of the lesion was performed, and the patient presented with recurrence. The patient was started on systemic treatment and showed improvement of the clinical picture and reduction of the lesions, with continuous follow-up.

Keywords: Eyelid diseases, granuloma annulare, histopathology

How to cite this article:
Falcao VC, Abreu EB, Burnier JV, Burnier MN. Granuloma annulare in a young patient: An unusual presentation. Pan Am J Ophthalmol 2019;1:10

How to cite this URL:
Falcao VC, Abreu EB, Burnier JV, Burnier MN. Granuloma annulare in a young patient: An unusual presentation. Pan Am J Ophthalmol [serial online] 2019 [cited 2023 Sep 27];1:10. Available from: https://www.thepajo.org/text.asp?2019/1/1/10/268607

Introduction

Granuloma annulare (GA) is a benign dermatosis clinically characterized by firm, skin-colored nodules or papules, arranged in an annular configuration. It most commonly affects the extremities, the trunk, and rarely the face region. GA usually occurs in patients younger than 30 years and is more common in women.^[1] The most common variant of GA is localized GA; however, generalized, perforating, and subcutaneous nodular forms have also been described.^[2] GA of the periorbital region is rare and may mimic other lesions. The diagnosis should be based on anamnesis, location, appearance of the lesion, and pathological anatomy.^[3]

Case Report

A 16-year-old female patient reported to an ophthalmologist due to the appearance of asymptomatic lesions on upper eyelids of both eyes, simultaneously for 1 month [Figure 1]. She denied any other symptom or antecedent and did not use any continuous medication. On clinical examination, these sessile, skin-colored, and nodular lesions measured around 1 cm in the upper eyelid of OD and 2 cm in the upper eyelid of OS. The position of the eyelids and function were normal, with preserved mobility. Excisional biopsy was recommended to determine the diagnosis, which was performed with local anesthesia, with 2 mm margins and wedge resection, and was then sent to the pathologist for analysis.

Figure 1: Granuloma annulare in a young patient: bilateral nodular presentation involving the skin of the canthal region, upper eyelids

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Histopathological examination of the lesions revealed well-demarcated microscopic areas of collagen degeneration surrounded by histiocytes and a lymphoplasmacytic infiltrate, suggestive of annular granuloma. The absence of multinucleated giant cells evades other differential diagnoses [Figure 2] and [Figure 3].

Figure 2: Granuloma annulare in a young patient: histopathological features include lymphocytic infiltration with granulomatous inflammation displaying many histiocytes

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Figure 3: Granuloma annulare in a young patient: high magnification showing histiocytes surrounded by lymphocytes. There are areas of necrobioses inside the granulomas

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The patient continued to be monitored. A few weeks later, the palpebral lesions returned in the upper palpebral inner corner and were fixed, nodular, and symmetrical [Figure 4]. There were also two symmetrical lesions on the lower limbs. Treatment with iodine was initiated but not tolerated by the patient; therefore, Rifampicin 300 mg, ciprofloxacin 500 mg, and minocycline 100 mg (oral) were introduced once a month for 4 months. A significant reduction of the eyelid lesions was seen.

Figure 4: Granuloma annulare in a young patient: recurrent nodular legion in the upper eyelid, canthal area

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Discussion

Subcutaneous GA is a benign dermatologic condition that occurs in healthy children. It is characterized by papules, plates, or firm nodules organized in a ring form.^[4] Usually, periorbital GA is not considered a differential diagnosis of periorbital lesions in the pediatric population because it is uncommon in this site.^[4] Subcutaneous GA is synonymous with pseudo-rheumatoid nodule.^[5]

At the University of Michigan, in 1964, Mesara et al.^[6] studied periocular nodular lesions, which were named pseudo-rheumatoid nodules in ophthalmologic literature because they were pathologically identical to rheumatoid nodules. At the same time, these nodules were called GA in dermatological literature.^[7] Later, in 1994, Burnstine et al.^[8] published an article on two older patients with periocular nodular lesions at 60 and 62 years of age and begin to refer to this type of lesion as GA nodular, which later became the universal name for these lesions.^[7]

Differential diagnoses of molluscum contagiosum, basal cell epithelioma, neurofibroma, sarcoidosis, and other granulomatous diseases are common. The error in the diagnosis of the lesions can occur because they are often not in an annular pattern.^[5]

De Becker et al.^[4] conducted an analysis of 398 palpebral lesions in childhood, together with previous reports of periocular GA detailing the differential diagnosis of these lesions. Of these, 1% were subcutaneous GA (pseudo-rheumatoid nodule), of which the most common lesions found were chalazion, dermoid cysts, papilloma, pyogenic granuloma, nevus, hemangioma, neurofibroma, molluscum contagiosum, lymphangioma, and chronic inflammation.

The etiology of GA remains unclear; however, there are some possible suspected sources such as skin infections, insect bites, exposure to sunlight, and local trauma, which are commonly reported in association in children with the subcutaneous type of GA. GA has also been reported in sites with warts and herpes zoster, suggesting a viral etiology.^[7] In some patients who present the disease, a certain genetic predisposition has been found, as well as a higher incidence in diabetics.^[9]

Histologically, GA is characterized by the presence of histiocytes and lymphocytes around well-defined necrobiosis centers of degenerated collagen, fibrin, and excess mucin between areas of the normal dermis.^[7]

Vasculitis is not usually found. Abundance of mucin is a feature of GA and may be helpful in the differentiation of the disease with other noninfectious granulomatous diagnoses, such as sarcoidosis and lipid necrobiosis.^[10] Eosinophils are frequently found in inflammatory cells around necrotic centers in subcutaneous GA.^[5]

However, GA should be distinguished from sarcoidosis as both may have common clinical symptoms and histopathological findings. Sarcoidosis can occasionally be differentiated histologically by the lack of infiltrates of inflammatory cells.^[7]

In 2013, Kang et al. reported the case of a 51-year-old woman with an orbital mass that underwent excisional biopsy and presented histologically identical to GA. Pathological findings showed poorly defined granulomas with chronic central necrosis and degenerated collagen, consistent with GA findings. However, the patient was diagnosed with sarcoidosis after a complete systemic investigation.^[11]

De Becker et al.^[4] in their literature research found 4 children (age 16 years or less) with a proven biopsy for GA who developed bilateral intermediary uveitis or bilateral panuveitis. The location of skin lesions was described in only one patient (hands and one ankle). In four cases, GA and uveitis occurred 4 months to 17 years apart, with cutaneous lesions appearing 4 months after uveitis in one patient. Two of these children also had retinal vasculitis, while the other two developed cystoid macular edema with permanently impaired visual acuity. In these four children, systemic evaluation was negative. The association with uveitis is not frequent enough to systemically track all patients with subcutaneous GA.

There are many treatments for GA. However, treatment is not always necessary as these lesions tend to disappear within months to decades. Treatment may be local or systemic. Local treatments include cryotherapy, excision, radiotherapy, laser treatment, and electrocoagulation. Systemic agents include antimalarials, thyroxin, potassium iodide, and dapsone.^[7] Topical and intralesional steroids are the most common forms of treatment.^[5]

Excision of the GA lesions is not curative, with 20% of patients showing recurrence after excision. Excisional biopsy is useful for diagnostic purposes and should be performed on at least one lesion. Recurrent lesions at the site of excision resolve faster than original lesions.^[5]

The majority of GA of the eyelid is reported in children but is rare in the literature. As discussed above, the differential diagnosis is important in adult patients, mainly with granulomatous diseases such as sarcoidosis that presents clinically and histopathologically very similar. Histopathology is important for the diagnosis of GA and to differentiate it from other pathologies. The treatment is controversial, not always performed, but sometimes necessary, especially in cases of relapse of the disease.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Chiang K, Bhalla R, Mesinkovska NA, Piliang MP, Tamburro JE. Periocular granuloma annulare: A case report and review of literature. Pediatr Dermatol 2014;31:722-5.
2.	Sandwich JT, Davis LS. Granuloma annulare of the eyelid: A case report and review of the literature. Pediatr Dermatol 1999;16:373-6.
3.	Moegelin A, Thalmann U, Haas N. Subcutaneous granuloma annulare of the eyelid. A case report. Int J Oral Maxillofac Surg 1995;24:236-8.
4.	De Becker I, Summers CG, Kaye V, Traboulsi EI, Schoenfield L, Markowitz G, et al. Periocular granuloma annulare in four children. J AAPOS 2010;14:280-2.
5.	McNeal S, Daw JL Jr. Subcutaneous granuloma annulare: An unusual presentation in the eyelids and scalp. Ann Plast Surg 2005;55:684-6.
6.	Mesara BW, Brody GL, Oberman HA. “Pseudorheumatoid” subcutaneous nodules. Am J Clin Pathol 1966;45:684-91.
7.	Kassardjian M, Patel M, Shitabata P, Horowitz D. Management of periocular granuloma annulare using topical dapsone. J Clin Aesthet Dermatol 2015;8:48-51.
8.	Burnstine MA, Headington JT, Reifler DM, Oestreicher JH, Elner VM. Periocular granuloma annulare, nodular type. Occurrence in late middle age. Arch Ophthalmol 1994;112:1590-3.
9.	Sánchez Tocino H, Galindo Ferreiro A, Galindo Alonso J, González López A, Martín Castillo J. Granuloma annulare of the eyelid: An unusual presentation. Arch Soc Esp Oftalmol 2004;79:397-400.
10.	Wang J, Khachemoune A. Granuloma annulare: A Focused review of therapeutic options. Am J Clin Dermatol 2018;19:333-44.
11.	Kang JJ, Aakalu VK, Lin A, Setabutr P. Orbital granuloma annulare as presentation of systemic sarcoidosis. Orbit. 2013 Dec;32(6):372-4. doi: 10.3109/01676830.2013.812125. Epub 2013 Jul 29.