Granuloma Annulare Differential Diagnosis Table

Granuloma Annulare Differential Diagnosis Table:

It is a benign, long-lasting, self-limiting, inflammatory skin disorder that results in small, smooth, annular, raised, discolored rash or bumps that make a ring with a normal or depressed center. It is more common in women and children.
The exact cause of granuloma annulare is idiopathic, but it is found to be associated with certain diseases like thyroid disease, increased cholesterol, Epstein-Barr virus, HZV, HIV, certain drugs, injury, and Diabetes Mellitus.
There are many hypotheses about the pathophysiology, but the most favorable is that it is a delayed hypersensitivity reaction, more precisely a Th1 reaction that causes macrophages to stimulate matrix metalloproteinases. This, then, results in connective tissue degradation.
It is diagnosed on clinical examination, but a skin biopsy can also be performed. It is usually treated with corticosteroid creams, lotions, and intralesional steroid injections.

How To Distinguish Granuloma Annulare From Other Diseases

Distinguish Epidermomycosis from Granuloma Annulare – Diagnosis

Epidermomycosis is a rare infection of the skin (stratum corneum) caused by fungal infection to yeast species such as Candida albicans and certain molds. The features that differentiate epidermomycosis and granuloma annulare are:

• Epidermomycosis is caused by fungal infection, while granuloma annulare’s exact cause is unknown.
• Epidermomycosis is mostly painless, while granuloma annulare develops painful bumps.
• Although both conditions are self-limiting, the former usually takes one week to resolve, while granuloma annulare persists from months to years.
• Both lesions are ring-shaped, but epidermomycosis spreads from the center to periphery, and granuloma annulare can be normal or depressed from the center.

Epidermomycosis is diagnosed on the history and examination of the lesion, while culture can also be performed. It is self-limiting but can be treated with antifungal creams and lotions.

Distinguish Discoid Lupus Erythematosus from Granuloma Annulare – Diagnosis

Discoid Lupus Erythematosus (DLE) is an autoimmune skin disease. It causes plaques on the scalp, ears, and face, which are persistent and scaly. The features that distinguish DLE and granuloma annulare are:

• It is an autoimmune disease, while granuloma annulare is thought to be caused by certain infections, injuries, or drugs, but the exact cause is idiopathic.
• It shows photosensitivity to UV rays of the sun, while granuloma annulare doesn’t show photosensitivity.
• DLE progresses into scarring, discoloration, and permanent hair loss from the affected area, while granuloma annulare progresses from a 0.5cm papule to 5cm in diameter.

Diagnosis is usually made by looking at the lesion and alopecia. Skin biopsy is used to confirm the diagnosis. Treatment options are protection from the sun, steroid injection in lesions, and topical calcineurin inhibitors.

Distinguish Sarcidosis from Granuloma Annulare – Diagnosis

Sarcoidosis is a rare disease in which the immune system reacts against the body’s own healthy cells, resulting in the formation of lumps called granulomas that deposit in different organs. Symptoms include shortness of breath, cough, eye pain, and soreness on shins. The features that differentiate sarcoidosis and granuloma annulare are:

• Sarcoidosis is a disease of the lungs and lymph nodes, but it may affect any organ like the heart, nervous system, eyes, liver, and skin, while granuloma annulare is a disease of the skin affecting hands and feet.
• Sarcoidosis forms tiny non-caseating granulomas, while granuloma annulare has small, raised, ring-shaped bumps with a sunken or normal center.
• Sarcoidosis can cause disease in any age group but is rare in children, while granuloma annulare is more common in children and women.
• Sarcoidosis is an autoimmune disease, while granuloma annulare is not an immune-related disease.

It is hard to diagnose, but blood and urine tests, CT scans, and biopsy can be done to assess the status of the disease. Corticosteroids are used to treat sarcoidosis.

Distinguish Syphilis from Granuloma Annulare – Diagnosis

Syphilis is a communicable disease caused by bacteria, Treponema Pallidum. Symptoms of syphilis are rashes on palms and soles, painless sores on genitals and mouth, fever, sore throat, hair loss, headache, myalgias, weight loss, and inflamed glands. The features that distinguish Syphilis from granuloma annulare are:

• Syphilis spreads through sexual contact, oral, or anal sex, while granuloma annulare is a non-infectious disease.
• Syphilis presents with painless sores, while granuloma annulare has painful plaques and bumps.
• Syphilis becomes latent if not treated, but it can relapse and progress to the next stage, so treatment is necessary to cure it, while granuloma annulare is benign and self-limiting.
• Syphilis progresses as primary, secondary, early latent, and late latent syphilis, while granuloma annulare can be localized, generalized, subcutaneous, and perforating.

Syphilis is diagnosed on history, examination of sores, blood tests, and fluid examination of genital or oral sores. Antibiotics, Benzathine penicillin G is used for treating syphilis.

Distinguish Rheumatoid Nodule from Granuloma Annulare – Diagnosis

Rheumatoid nodule is a firm, soft nodule present under the skin near joints. It is caused by excessive smoking, injury near pressure points, drugs used for arthritis, and patients suffering from severe rheumatoid arthritis. The features that distinguish rheumatoid nodule from granuloma annulare are;

• Rheumatoid nodules are well-circumscribed, skin-colored, freely movable subcutaneous nodules, while granuloma annulare has a small, smooth, ring-shaped, discolored rash or bump with a normal or depressed center.
• Rheumatoid nodules mostly develop on the extensor surface or weight-bearing areas like forearms, elbows, Achilles tendon, heels, and finger joints, while granuloma annulare is usually located on hands and feet.
• Rheumatoid nodule is considered to be autoimmune, while granuloma annulare’s mechanism of action is still unknown.

Diagnosis is based on the history of rheumatoid arthritis and examination of the nodule. Biopsy, blood tests, and antibody tests can also be performed. Steroids and surgical excision are good treatment options.

Distinguish Necrobiosis Lipoidica from Granuloma Annulare – Diagnosis

Necrobiosis lipoidica is a rare granulomatous inflammation and chronic collagen degeneration disease. Symptoms include a rash with shiny, raised red-brown discoloration and a yellowish center, mostly seen on lower legs. The features that distinguish this disease from granuloma annulare are;

• Both diseases are more common in ladies, but the former is present on shins while the latter is present on hands and feet.
• Necrobiosis has thickened blood vessels and fat deposition, while in granuloma annulare, there are multinucleated giant cells and histiocytes surrounding the necrobiosis and increased mucin precipitation.
• Biopsy is performed to distinguish necrobiosis lipoidica from granuloma annulare.

It is diagnosed based on the history and examination of lesions, while biopsy is also useful. Anti-inflammatory drugs and corticosteroids are proven helpful in the treatment.

Distinguish Lichen Planus Annularis from Granuloma Annularis – Diagnosis

Lichen Planus Annularis is a rare and chronic variant of lichen planus. It causes circular, slightly elevated, purple plaques with clear centers and intact central tissue. It develops on the skin, inside the oral cavity, and male genitals. The features which distinguish lichen planus annularis from granuloma annulare are;

• Lichen Planus Annularis is found to be an autoimmune disease while granuloma annulare is not proven to be an autoimmune disease.
• Lichen planus annularis is found on the skin, mouth, scrotum, and penis while granuloma annulare is found on hands and feet.
• Both lesions are ring-shaped, but planus annularis has central clearance while granuloma annulare has a depressed center.

It is diagnosed based on clinical examination and history, but biopsy should be performed to confirm the diagnosis and rule out malignancy. It is difficult to treat, but corticosteroids, immunosuppressant drugs, and antihistamine drugs are proven useful.

Important Red Flags in Granuloma Annularis

If a person is suffering from diabetes and thyroid disease, he is more likely to get granuloma annulare. So, if small, raised, and discolored ring-shaped lesions with a sunken center are formed on the skin of hands and feet that are not going away for weeks, then a person should definitely consult a doctor.