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Year : 2014  |  Volume : 59  |  Issue : 6  |  Page : 636
Annular lesions located on the right forearm

Department of Specialized, Diagnostic and Experimental Medicine, Division of Dermatology, University of Bologna, Bologna, Italy

Date of Web Publication30-Oct-2014

Correspondence Address:
Vera Tengattini
Department of Specialized, Diagnostic and Experimental Medicine, Division of Dermatology, University of Bologna, Via Massarenti 1, Bologna - 40138
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.143611

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How to cite this article:
Pileri A, Tengattini V, Bardazzi F, Misciali C, Patrizi A. Annular lesions located on the right forearm. Indian J Dermatol 2014;59:636

How to cite this URL:
Pileri A, Tengattini V, Bardazzi F, Misciali C, Patrizi A. Annular lesions located on the right forearm. Indian J Dermatol [serial online] 2014 [cited 2020 Aug 15];59:636. Available from:

   Clinical History Top

A 72-year-old Caucasian woman was referred to us because of presence of annular lesions located on the right forearm and present for 3 years. Notably, the patient had been affected by multiple myeloma (MM) immunoglobulin G (IgG)/lambda (stage IA) since 2005, in complete remission for 3 years.

Physical examination revealed erythematous, nonscaling lesions set on the right forearm measuring from 1 to 4 cm [Figure 1].
Figure 1: Initial clinical presentation: Lesions were set on the right forearm measuring from 1 to 4 cm

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The patient did not complain any itch from the lesions nor reported any previous intake of drugs. A punch biopsy revealed a lymphohistiocytic infiltrate, degenerated collagen, and mucin deposition [Figure 2].
Figure 2: Histopathology of lesion showing area of degenerated collagen, lymphohistiocytic infi ltrate, mucin deposition, and giant cells (H and E, ×40).

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   Question Top

What's your diagnosis?

   Answer Top


Atypical granuloma annulare (GA) associated with a multiple myeloma (MM ) relapse.

   Clinical Course Top

Initially, the patient was treated with daily betametasone ointment for 1 month without any improvement. Then, monthly triamcinolone acetonide subcutaneous infiltration was started, but was discontinued after 3 months without any improvement. Thereafter, 0.1% tacrolimus ointment was administered. After 2 months, the lesions began to turn pale and at the last follow-up the condition was stable [Figure 3]. In the meantime, the patient suffered an MM relapse and a cycle of melphalan chlorhydrate and prednisone was started.
Figure 3: After 6 months the lesions kept about the same size, although began to turn pale

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   Discussion Top

GA is a benign, self-limiting, granulomatous dermatitis characterized by annular lesions, set on acral areas, such as the dorsum of the hands and feet. Women are most commonly affected. The etiology is still unclear, but it is thought that cell-mediated delayed type hypersensitivity could be involved. The appearance of GA has been reported in association with several diseases such as viral infections (e.g., Epstein-Barr virus, hepatitis C virus (HCV), and HIV), systemic illnesses (diabetes mellitus, thyroiditis, tuberculosis). [1] Furthermore, GA can precede or follow internal malignancies such as breast or colon carcinomas, Hodgkin and non-Hodgkin lymphoma, and leukemia (acute myelogenous leukemia, large granular lymphocytic leukmia). [2] In these cases, the clinical presentation can be polymorphous, including painful skin lesions on palms or soles. [3] Patients are commonly older than 60 years. The disease can often improve if the concomitant malignancy is successfully treated. GA therapies vary from psoralen + ultraviolet (PUVA) to topical and intralesional corticosteroids, antimalarials, pentoxifylline, retinoids, cyclosporine, laser, oral calcitriol, and dapsone. [4] However, it has not yet been established whether or not one of these should be considered as the best choice. [5]

There is an ongoing debate as to whether GA should be considered a paraneoplastic condition. However, many papers report GA in association with hematologic malignancies. [3]

In our case GA eruption was not the presenting symptom. GA eruption presented when MM began relapsing after 3 years of complete remission. However, the relapse was observed 3 years after the eruption. This finding corroborates with the experiences of Hinckley et al., [6] and Vestey et al., [7] with four GA cases characterized by an underlying myelodysplastic syndrome. In particular, two patients presented an acute myeloid leukemia.

To our knowledge, we report for the first time a case of MM presenting a GA eruption. This case leaves open the question whether GA eruption should be considered as a paraneoplastic lesion, both in terms of predicting and as sign of clinical worsening.

   References Top

1.Ratnarathorn M, Raychaudhuri SP, Naguwa S. Disseminated granuloma annulare: A cutaneous adverse effect of anti-TNF agents. Indian J Dermatol 2011;56:752-4.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Mascaró JM Jr. Cutaneous signs of hematologic malignancies: "Doctor, is there something wrong with my blood?". Arch Dermatol 2011;147:342-4.  Back to cited text no. 2
3.Barksdale SK, Perniciaro C, Halling KC, Strickler JG. Granuloma annulare in patients with malignant lymphoma: Clinicopathologic study of thirteen new cases. J Am Acad Dermatol 1994:31:42-8.  Back to cited text no. 3
4.Boyd AS. Granuloma annulare responsive to oral calcitriol. Int J Dermatol 2012;51:120-2.  Back to cited text no. 4
5.Ezra N, Ahdout J, Haley JC, Chiu MW. Granuloma annulare in a zoster scar of a patient with multiple myeloma. Cutis 2011;87:240-4.  Back to cited text no. 5
6.Hinckley MR, Walsh SN, Molnár I, Sheehan DJ, Sangueza OP, Yosipovitch G. Generalized granuloma annulare as an initial manifestation of chronic myelomonocytic leukemia: A report of 2 cases. Am J Dermatopathol 2008;30:274-7.  Back to cited text no. 6
7.Vestey JP, Turner M, Biddlestone L, McLaren K, Goulden N, Hunter JA. Disseminated cutaneous granulomatous eruptions associated with myelodysplastic syndrome and acute myeloid leukaemia. Clin Exp Dermatol 1993;18:559-63.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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