Diabetes, Granuloma Annulare, Hypersensitivity, PUVA, Teledermatology



  1. Ivey, Lauren A.
  2. Wahjudi, Ingrid
  3. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a teledermatology case of an annular, papular eruption on both knees, ankles, and knuckles.


Article Content

In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.




Chief complaint: presenting for diagnosis and therapeutic options


History of present illness

A 69-year-old gentleman presents with red, ring-shaped plaques on his ankles, knuckles, and knees, which he says developed over the last several weeks. Prior treatment for skin condition: none. Primary symptom: intermittent pruritus. Prior biopsy: none. Past medical and medication history is significant for colorectal cancer, herpes zoster infection, and diabetes mellitus (DM), controlled with metformin.



Fully satisfactory.



One image was provided that showed well-demarcated erythematous annular plaques with sunken central clearing and an aggregation of mamillated pink papules located symmetrically on the knees, lateral ankles, and elbows bilaterally (see Figure 1).

Figure 1 - Click to enlarge in new windowFIGURE 1. The presented lesion shows several reddish papules with a hypopigmented to reddish center.


Lesion A


The morphology of the lesions, distribution, and history are characteristic for granuloma annulare.



Skin Care Recommendations

Gentle cleansers and pat dry; no rubbing. Apply emollient two times a day.


Medication Recommendations

Topical corticosteroids are the mainstay of treatment for episodic pruritus. Recommend triamcinolone 0.1% ointment (or a similar midpotency ointment) twice daily.



Type of Visit

Refer to dermatology for face-to-face assessment if there is no improvement in 10-12 weeks after initiating topical corticosteroid therapy.



Granuloma annulare (GA) is a benign granulomatous inflammatory disorder of unknown etiology, which may be triggered by trauma or by certain medications (e.g., tumor necrosis factor alpha inhibitors, allopurinol, topiramate, and gold therapy) (Piette & Rosenbach, 2016). Clinical variants of granuloma annular include localized GA, generalized GA, subcutaneous GA (more common in young children), perforating GA, and arcuate dermal erythema. Localized GA is the most common type (occurring in about 75% of cases) and is largely asymptomatic, resolving within a few years (Lyons & Ousley, 2014; Strazzula, Wong, Burgin, & Goldsmith, 2019). GA's histopathologic features include a lymphocytic infiltrate, degeneration of collagen, and mucin deposition (Lima, Illing, Schliemann, & Elsner, 2017).


GA has a predilection for the fingers, hands, elbows, dorsal feet, or ankles as a collection of small papules that coalesce to form annular or arcuate erythematous plaques (Strazzula et al., 2019). Furthermore, women are twice as frequently affected (Strazzula et al., 2019). GA is largely asymptomatic; however, mild pruritus and pain can be bothersome for a minority (25%) of patients with the disease (Cyr, 2006). Some studies have reported GA to occur in a seasonal pattern, potentially because of an increase in exposure to ultraviolet light (Piette & Rosenbach, 2016).


A cell-mediated hypersensitivity reaction is favored as the underlying pathophysiologic mechanism for developing GA (Keimig, 2015). Specifically, activation of macrophages via the production of interferon gamma (INF-[gamma]) by immune-mediated Th1 cells has been suggested (Asai, 2017). Tumor necrosis factor alpha antagonists are used in the treatment of GA and have been shown to have beneficial effects, which would support this mechanism.


Whereas corticosteroids and topical calcineurin may be efficacious in localized GA, generalized GA may be recalcitrant to standard of care therapies. Some success has been reported with the combination of PUVA, isotretinoin, dapsone, and hydroxychloroquine (Strazzula et al., 2019). GA has been reported in association with DM, and patients with a confirmatory diagnosis of GA should be evaluated for DM (Lyons & Ousley, 2014; Piette & Rosenbach, 2016).




Asai J. (2017). What is new in the histogenesis of granulomatous skin diseases? The Journal of Dermatology, 44(3), 297-303.[Context Link]


Cyr P. R. (2006). Diagnosis and management of granuloma annulare. American Family Physician, 74(10), 1729-1734. [Context Link]


Keimig E. L. (2015). Granuloma Annulare. Dermatologic Clinics, 33(3), 315-329.[Context Link]


Lima A. L., Illing T., Schliemann S., Elsner P. (2017). Cutaneous manifestations of diabetes mellitus: A review. American Journal of Clinical Dermatology, 18(4), 541-553.[Context Link]


Lyons F., Ousley L. (2014). Granuloma annulare. In Dermatology for the advanced practice nurse. (pp. 163-167). New York, NY: Spencer Publishing Company.[Context Link]


Piette E. W., Rosenbach M. (2016). Granuloma annulare. Journal of the American Academy of Dermatology, 75(3), 467-479.[Context Link]


Roman M., Jacob S. S. (2015). Teledermatology: Virtual access to quality dermatology care and beyond. Journal of the Dermatology Nurses' Association, 6(6), 285-287. doi:10.1097/jdn.0000000000000086 [Context Link]


Strazzula L., Wong V., Burgin S., Goldsmith L. A. (2019). Granuloma annulare in adult. In Goldsmith L. A. (Ed.), VisualDx. Rochester, NY: VisualDx. Retrieved from[Context Link]


1The standardized teledermatology reader report format is available for authors on the journal's Web site ( and on the submissions Web site online at [Context Link]