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Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 39-41

Subcutaneous granuloma annulare in a child: A rare presentation

1 Department of Dermatology, Thanjavur Medical College, Chennai, India
2 Department of Dermatology, Sri Balaji Medical College, Chennai, Tamil Nadu, India

Date of Web Publication24-Jun-2014

Correspondence Address:
Kumar Parimalam
No. 33, East Ellaiamman Koil Street, Dr. Radhakrishnan Nagar, Thiruvottiyur, Chennai - 600 019, Tamil Nadu
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We present a rare case of subcutaneous granuloma annulare (SGA) of the palm in a 3-year-old girl disappearing on removal of a SGA of the dorsum of foot. Though GA is more common in children, subcutaneous type is rare and poses diagnostic difficulty. Very few cases of SGA over the palm have so far been reported. Disappearance of SGA of the palm following removal of a nodule from the foot represents remote reverse Koebner's phenomenon.

Keywords: Childhood, subcutaneous granuloma annulare, palm, reverse Koebner phenomenon

How to cite this article:
Parimalam K, Thomas J. Subcutaneous granuloma annulare in a child: A rare presentation. Indian J Dermatopathol Diagn Dermatol 2014;1:39-41

How to cite this URL:
Parimalam K, Thomas J. Subcutaneous granuloma annulare in a child: A rare presentation. Indian J Dermatopathol Diagn Dermatol [serial online] 2014 [cited 2023 Mar 20];1:39-41. Available from: https://www.ijdpdd.com/text.asp?2014/1/1/39/135197

  Introduction Top

Granuloma annulare (GA) is a benign, usually self-limiting granulomatous disease of the dermis and subcutaneous tissue. Localized, generalized, perforating, and subcutaneous forms are the common types. The subcutaneous form also known as deep GA or pseudo rheumatoid nodule is commonly seen over the extremities in children. [1] However, palmar lesions pose diagnostic difficulty, especially when the morphology of lesions is different. [2] Histological confirmation is required under such circumstances, which shows multiple small foci of palisading granulomas with necrobiosis in the dermis and subcutis. Special stains such as colloidal iron and alcian blue can be used to demonstrate mucin in doubtful cases. Reverse Koebner's phenomenon is unique for GA and not seen in other palisading granulomas.

  Case Report Top

A 3-year-old healthy child presented with asymptomatic rapidly growing nodule over the dorsum of right foot of 40 days duration. There was no history of trauma preceding its onset. On physical examination, she had a skin-colored, painless dome-shaped nodule 3 cm in diameter, over the dorsum of right foot. The skin over the nodule was stretched and there was a thin collarette of hyper keratosis at the base of the nodule. The sole was normal. Examination of the hands revealed a mildly erythematous deep seated nodule, 1.5 cm in diameter near the thenar eminence and a small nodule of 1 cm size over the proximal phalanx of left index finger [Figure 1], which the mother seemed to have noticed 20 days after the appearance of the first lesion and was also asymptomatic. Rest of the skin and mucosae were normal. An excision biopsy was done from the foot nodule which revealed foci of collagen degeneration with palisading lymphohistiocytes in mid and lower dermis extending to the subcutis consistent with SGA [Figure 2]. There were no giant cells. The child's hemogram and blood sugar were normal. On the seventh day after the biopsy, the palmar lesion showed considerable reduction in size and almost resolved in three weeks. However, there was mild residual pigmentation. The nodule over the index finger healed from the center followed by resolution at the periphery [Figure 3]. There was no recurrence during the two-year follow-up period.
Figure 1: Domeshaped nodule over dorsum of foot, erythematous ill-defined nodules over palm in a child with SGA

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Figure 2: Pallisading lymphohistiocytes around focus of degenerated collagen (H and E, ×400)

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Figure 3: Resolving palmar nodules after excision of foot nodule in a child with SGA

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  Discussion Top

Granuloma annulare is a benign, relatively common dermatosis in childhood. The subcutaneous form is rare, and lesions typically occur on the legs, buttocks and scalp. The exact etiology of GA is unknown. Insect bite, trauma, sun exposure, tuberculin skin testing, ingestion of allopurinol or vitamin D, viral infections (Epstein-Barr virus, herpes simplex virus, human immunodeficiency virus (HIV)), thyroiditis are some of the proposed etiological factors. Trauma appears to be the most probable association in children, with subcutaneous GA (SGA). GA lesions are usually asymptomatic papules and plaques, which slowly increase in size though pruritic lesions over palms are reported in adults. [3]

The subcutaneous form is characterized by lesions on the extremities and scalp and by its predilection for pediatric age group. [4] In 25% of cases, they are associated with superficial papules. Palms and soles are uncommon sites. [5] A history of rapid growth and multiple recurrences can mimic a malignant lesion. [6]

Differential diagnoses for SGA include digital fibromatosis, xanthomas, rheumatoid nodules, soft tissue tumors, bone tumors and calcified hematoma, rhabdomyosarcoma, giant-cell fibroblastoma, fibromatosis, plexiform fibrohistiocytic tumor, epithelioid sarcoma, malignant fibrous histiocytoma, and juvenile xanthogranuloma. [7]

An incisional or excisional biopsy examination is diagnostic but neither is curative because recurrence or development of subsequent lesions may occur in a high proportion of patients. However, histology is important to differentiate SGA from other soft tissue lesions. The pathognomic histologic feature of SGA is a palisading granuloma showing a central area of necrobiosis with a peripheral zone of inflammation in which the infiltrates are in a palisade-like arrangement. The areas of necrobiosis, are often larger than in the superficial type. These foci are distributed in the deep dermis, subcutis and, rarely, deep soft tissues. Eosinophils are more common in this form. Immunofluorescence studies have shown fibrin in areas of necrobiosis and IgM and C3 in blood vessel wall. [8] Histiocytes seen in clinically typical GA, can mimic a malignant lesion as they often have increased mitotic rate. In GA, local immunologically distinct population of histiocytes proliferate after a variety of different insults, and further, mesenchymal cells in the dermis are transformed into histiocytes with phagocytic properties which when activated, release enzymes such as matrix metalloproteinase (MMP)-2 and MMP-9 that lyse the collagen and elastic fibers which they surround and invade. It is postulated that the destructive potential of the inflammatory cells in GA is restricted by activation- induced apoptosis [9] and insufficient control of the lesion by apoptosis may lead to recurrence. Insulin-dependent diabetes mellitus has been reported in children with GA. [10]

SGA typically resolves spontaneously, although, most lesions persist for months to years. The annular morphology in the resolving lesion in our case could be due to the destructive potential of the inflammatory cells, probably causing minimal loss of dermal tissue leading to central depression. The pigmentation seen over the palm may be attributed to the post inflammatory response. Pigmentary changes have been reported in GA treated with rifampin, ofloxacin, and minocycline hydrochloride. Treatment is also not indicated even for recurrent lesions. Non-steroidal anti-rheumatics, dapsone, and intralesional injections of triamcinolone have been proposed for those cases resistant to spontaneous healing. Reverse Koebner response is disappearance of the lesions of a particular dermatosis at the site of injury, and commonly seen in GA, psoriasis, vitilgo and vasculitis. Remote reverse Koebner phenomenon was observed in treated cases of vitiligo where spontaneous repigmentation of vitiligo patches occurred distant from the autologous skin graft sites. In our case, palmar nodules cleared spontaneously on removal of the foot lesion probably exhibiting remote reverse Koebner's phenomenon.

  Conclusion Top

In children, the lower extremities seem to be involved more frequently. In few reports that are available on SGA of the palm, there was no associated SGA of the foot. Our report seems to be the first pediatric case were SGA of the palm was associated with that of the dorsum foot and palmar lesions resolved within 20 days of removal of the foot nodule. In this case, biopsy was both diagnostic and therapeutic.

  References Top

1.Takeyama J, Sanada T, Watanabe M, Hatori M, Kunikata N, Aiba S. Subcutaneous granuloma annulare in a child′s palm: A case report. J Hand Surg Am 2006;31:103-6.  Back to cited text no. 1
2.Mur EC, Fernandez CM, Hermosa JM. Bilateral and subcutaneous palmar nodules in a 2-year-old child suggesting deep granuloma annulare. J Eur Acad Dermatol Venereol 2005;19:100-3.  Back to cited text no. 2
3.Hsu S, Lehner AC, Chang JR. Granuloma annulare localized to the palms. J Am Acad Dermatol 1999;41:287-8.  Back to cited text no. 3
4.Trobs RB, Borte M, Voppmann A, Weidenbach H, Thiele J. Granuloma annulare, nodular type: A subcutaneous pseudo-rheumatoid lesion in children. Eur J Pediatr Surg 1997;7:349-52.  Back to cited text no. 4
5.Grant I, Mohammed P, Mahaffey PJ. Granuloma annulare in the hand. J Hand Surg 2002;27:556-8.  Back to cited text no. 5
6.Letts M, Carpenter B, Soucy P, Davidson D. Subcutaneous granuloma annulare of the extremities in children. Can J Surg 2000;43:425-30.  Back to cited text no. 6
7.Gross E, Rao BN, Pappo AS, Michalkiewicz E, Hudson MM, Kaste SC, et al. Soft tissue sarcoma of the hand in children: Clinical outcome and management. J Pediatr Surg 1997;32:698-702.  Back to cited text no. 7
8.Smith MD, Downie JB, DiConstanzo D. Granuloma annulare. Int J Dermatol 1997;36:326-33.  Back to cited text no. 8
9.Fayyazi A, Schweyer S, Eichmeyer B, Herms J, Hemmerlein B, Radzun HJ, et al. Expression of IFN gamma, co-expression of TNF alpha and matrix metallo-proteinases and apoptosis of T lymphocytes and macrophages in granuloma annulare. Arch Dermatol Res 2000;292:384-90.  Back to cited text no. 9
10.Grogg KL, Nascimento AG. Subcutaneous granuloma annulare in childhood: Clinicopathologic features in 34 cases. Pediatrics 2001;107:E42.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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