Treatment of Granuloma Annulare Using Tapinarof Cream 1.

Granuloma annulare is a benign, non-infectious cutaneous granulomatous disease. Its pathogenesis is not completely elucidated but has recently been thought to involve immunologic and cytokine receptor signaling dysregulation. This includes the involvement of both Th1 and Th2 pathways as well as Th17 and Th22 axes and the Janus kinase/signal transducers and activators of the transcription (JAK-STAT) pathway. First-line treatment is typically intralesional or topical corticosteroids, however, these therapies do not always provide consistent, long-term efficacy for all patients. The successful use of therapies that target the specific inflammatory and immunologic mechanisms that underlie the pathogenesis of GA has been described. Here we describe a case of long-standing GA treated with tapinarof cream 1% applied once daily for 30 days. To our knowledge, this treatment has not yet been adequately described in the literature. J Drugs Dermatol. 2024;23(10):889-893.  doi:10.36849/JDD.8321.

Granuloma annulare and possible relation to purified protein derivative administration: a case report.

BACKGROUND: Granuloma annulare is a noninfectious inflammatory granulomatous skin disease characterized by an erythematous or skin colored annulare plaque. The diagnosis of granuloma annulare may be challenging owing to its diverse morphology. In such cases, a correlation between the clinical findings and histologic findings are necessary. CASE PRESENTATION: We report a case of granuloma annulare after purified protein derivative administration. A 56-year-old Caucasian female patient complained of mildly pruritic rashes which started on both arms and lower extremities, and eventually spread to both thighs, the left popliteal region, left upper back, and the right abdominal area. About 6 weeks prior to the eruption of the rashes, the patient had been given a purified protein derivative tuberculin skin test. Biopsy specimens revealed dermal histiocytes palisading around areas of mucin and degenerated collagen, confirming granuloma annulare. After treatment with 0.1% topical triamcinolone acetanide and 500 mg oral metronidazole, the patient's lesions resolved. DISCUSSION: Relatively little is known about granuloma annulare's exact etiology. Granuloma annulare has four variations presenting as either localized, generalized, subcutaneous, or perforating and patch granuloma annulare. The clinical prognosis for granuloma annulare varies according to clinical subtypes. Proposed causal mechanisms of subcutaneous granuloma annulare include physical trauma, infections, immunizations, insect bites, diabetes mellitus, and alterations in the cell-mediated immune responses. The disease likely has an inflammatory component. Clinically, granuloma annulare may be confused with many other skin diseases. CONCLUSION: This case of subcutaneous granuloma annulare was reported since it is a rare dermatologic pathological condition that can be confused with other skin rash disorders. Although it is a benign self-limited disease, definitive diagnosis is important to rule out other pathologies with similar clinical appearances, such as cancer or human immunodeficiency virus (HIV) infection. Diagnostic confirmation is best made through skin biopsy.

Oral abrocitinib in the treatment of granuloma annulare: a case report.

Aim: To evaluate the therapeutic efficacy and safety of JAK inhibitor abrocitinib in patients with localized granuloma annulare (GA) and to review the available cases documented in English.Methods: We presented a patient who had a persistent, localized granuloma anulare (GA) for one year and did not respond to traditional therapies. This patient was treated with oral abrocitinib at a dosage of 150 mg daily.Results: After 6 weeks of treatment with abrocitinib, the patient exhibited notable symptom improvement with no new lesions. No adverse events or recurrences were reported during the 5-month follow-up period.Conclusions: Abrocitinib may be a promising and safe treatment option for patients with localized GA who do not respond to traditional therapies.

Retrospective assessment of immunologic and histologic heterogeneity in granuloma annulare by cytokine staining.

BACKGROUND: Type 1 (Th1) and Type 2 (Th2) immunity have both been implicated in granuloma annulare (GA). To what extent these pathways contribute to clinical/histologic heterogeneity and/or distinct disease endotypes remains unexplored. METHODS: We retrospectively analyzed 30 GA biopsies with either palisaded or interstitial histology with and without eosinophils. We performed RNA in situ hybridization to assess how markers of Type 1 (interferon gamma), Type 2 (interleukin [IL]4, IL13, IL5), and Type 3 (IL17A) immunity in GA compared with canonical inflammatory disorders and whether markers correlated with histology. We analyzed another cohort of 14 patients who had multiple biopsies across anatomic space and time for individual conservation of histologic features. RESULTS: Interferon (IFN)G staining is highest in GA relative to other cytokines. Type 2 cytokine staining is less prominent, with IL4 increased in interstitial pattern cases. Eosinophils did not correlate with Type 2 markers. Patients with multiple biopsies display intrapatient variability in histology. CONCLUSION: Type 1 inflammation predominates over Type 2 inflammation in GA irrespective of histologic pattern. Distinct disease endotypes were not detected.

Granuloma annulare on ultrasound: a diagnosis to consider in pediatric skin lesions.

BACKGROUND: Granuloma annulare (GA) is a rare, benign, inflammatory, self-limited, granulomatous dermatosis that affects children and young adults. The most frequent clinical form is localized GA. Deep GA generally presents as painless palpable subcutaneous nodules in the lower extremities, buttocks, hands and scalp. They may have a fast-growing firm subcutaneous mass presentation, mimicking a malignant lesion which requires an imaging evaluation. Diagnosis of deep GA can be more difficult and imaging evaluation is frequently performed, ultrasound being one of the techniques used. OBJECTIVE: To describe the US characteristics of GA in a pediatric series. MATERIALS AND METHOD: Descriptive, retrospective, 14-year study of all pediatrics GA cases. RESULTS: Twelve pediatric cases with GA. 66% females. The lesions were mainly distributed in the extremities: 50% in the lower extremities and 42% in the upper extremities, mostly with multiple lesions. A total of 45 lesions were analyzed, 8 superficial lesions and 37 deep lesions. On ultrasound, the superficial GA corresponded to hypoechoic poorly defined solid plaque like or nodular lesions, located in the dermal-epidermal plane. The deep GA presented as solid nodular, poorly defined hypoechoic lesions that compromised the deep subcutaneous-aponeurotic plane. CONCLUSION: GA is an inflammatory lesion that presents as a superficial or deep palpable nodule that predominantly affects children. Superficial and deep GA present characteristic findings on US that can guide the diagnosis. The radiologist needs to know its US appearance to be able to suggest the diagnosis, especially in multiples lesions.

Granuloma annulare with alopecia areata in a 6-year-old girl: a case report.

BACKGROUND: Dermatologic signs and symptoms can be the manifestations of a single disease or different diseases, and it is proven that some are associated with one another. These connections are not fully understood, but the answer lies in the pathophysiology of each disease. CASE PRESENTATION: We report the case of a 6-year-old Middle-Eastern girl who presented with two skin lesions on the dorsum of her foot, along with scaling of her soles and palms, face skin discoloration, and areas of patchy alopecia on her scalp. She was diagnosed as a case of acute onset of granuloma annulare with alopecia areata and dermatitis. The treatment regimen for the patient's scalp consisted of topical minoxidil and betamethasone and three sessions with 1-month intervals of triamcinolone acetonide intralesional injections, which demonstrated modest effectiveness in treating alopecia areata. CONCLUSION: Granuloma annulare is a benign inflammatory illness with no known cause that might be difficult to cure. The clinical course and prognosis might vary greatly depending on the disease subtype, and associating symptoms and diseases, such as alopecia areata, should be considered.

Immunohistochemical Features of MMP-9 and pSTAT1 in Granuloma Annulare and Sarcoidosis: A Comparative Study of 62 Cases.

Background: Granuloma annulare (GA) and sarcoidosis are granulomatous inflammatory diseases that share similarities. Objective: To identify the histological and immunohistochemical (IHC) features of GA and sarcoidosis. Methods: A retrospective review of 36 patients with GA and 26 with sarcoidosis was performed. Results from hematoxylin and eosin (H&E) staining and IHC staining of MMP-9 and pSTAT1 within the skin lesions of GA and sarcoidosis were analyzed, and random forest was applied for developing a predictive model. Results: Significantly greater expressions of MMP-9 (especially in elastic fibers, EFs, P < 0.0001) and pSTAT1 (P = 0.0003) were observed in lesion samples of GA versus sarcoidosis patients. In GA patients, MMP-9 was significantly upregulated in the interstitial type (P = 0.0222), while staining of pSTAT1 was positively correlated with the area of mucinous collagen in palisading GA (R = 0.5356, P = 0.0484). In sarcoidosis patients, MMP-9 (R = -0.7127, P = 0.0009) and pSTAT1 (R = -0.5604, P = 0.0067) were found to show stronger expressions in lesions with less lymphocyte infiltration. The predictive model demonstrated an AUC of 0.9675. Conclusion: These results indicate that MMP-9 and pSTAT1 might exert roles in granulomatous inflammation in different modes, and the presence of more robust MMP-9 staining in EFs appears to be more suggestive of GA.

Periocular Granuloma Annulare: A Case Report of a Rare Childhood Disease in an Adult.

A 21-year-old female presented to the oculoplastic clinic with a 2-year history of raised lesions in the right upper eyelid and lateral canthus area. Due to their unusual appearance, the patient underwent an excisional biopsy of the lateral canthus lesion. A diagnosis of granuloma annulare was made after histopathology demonstrated palisading epithelioid granulomas with central fibrinoid necrosis and Alician blue positive acid mucin. Granuloma annulare is a benign inflammatory skin condition characterized by firm discolored papules or nodules classically arranged in an annular pattern. Periocular involvement is extremely rare in adults and may pose a diagnostic challenge to ophthalmologists unfamiliar with its presentation and management.