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E-IJD CASE REPORT |
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| Year : 2015 | Volume
: 60
| Issue : 5 | Page : 522 |
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| Asymptomatic papulo-nodules localized to one finger |
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Kinjal D Rambhia, Uday S Khopkar
Department of Dermatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| Date of Web Publication | 4-Sep-2015 |
Correspondence Address:
Kinjal D Rambhia
B-105 Kalpataru Classic, Chincholi Bunder Road, Malad west, Mumbai - 400 064, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-5154.159654
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 Abstract | | |
Subcutaneous or deep granuloma annulare is a benign asymptomatic condition characterized by firm asymptomatic nodules in deep subcutaneous tissues that may be associated with intradermal lesions. A 53-year-old female presented with asymptomatic skin-colored, firm nodules over the right ring finger. Histopathology revealed a palisading granuloma with central degenerated collagen and mucin deposition in the dermis suggestive of granuloma annulare. Isolated and unilateral involvement of a single digit with clusters of nodules of subcutaneous granuloma annulare (GA) in an adult is rare and differentiation from its simulator rheumatoid nodule is essential.
Keywords: Finger, localized, mimicking, rheumatoid nodule, subcutaneous granuloma annulare
How to cite this article:
Rambhia KD, Khopkar US. Asymptomatic papulo-nodules localized to one finger. Indian J Dermatol 2015;60:522 |
What was known?
Subcutaneous GA is characterized by deep dermal or subcutaneous nodules and occurs usually in children.
| Introduction | |  |
Subcutaneous granuloma annulare (SGA) is rare in adults. Isolated and unilateral granuloma annulare occurring in clusters on the finger of an adult is rare. It is frequently misdiagnosed as a rheumatoid nodule due to its clinical and histopathological resemblance.
| Case Report | | |
A 53-year-old female presented with multiple asymptomatic skin-colored nodules over the right ring finger since 4 years [Figure 1]. Her past medical history was insignificant with no history of diabetes mellitus, hypertension, joint pains or connective tissue disease. Clinical examination revealed multiple skin-colored, non-tender, firm to hard nodules of varying sizes located over the dorsum of the right ring finger. Examination of the other fingers, toes, nails and hand joints did not reveal any abnormalities. Her hematological and biochemical investigations including a complete hemogram, liver and renal function tests, blood sugar estimations were within normal limits.
A skin biopsy of the nodule revealed an infiltrate of histiocytes in a palisading pattern surrounding an area of increased mucin and degenerated collagen present in the lower dermis extending up to the subcutaneous tissue [Figure 2] and [Figure 3]. There were few multinucleated histiocytes in the granuloma. The rest of the dermis shows a sparse superficial and deep perivascular lymphocytic infiltrate. | Figure 2: Palisading granuloma with mucin deposition and degenerated collagen (Hematoxylin and Eosin x10)
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Based on the clinical and histopathological findings, a diagnosis of isolated unilateral deep granuloma annulare localized to one finger was made. The patient was counseled of the benign nature of the disease.
| Discussion | | |
Granuloma annulare is a common, asymptomatic benign inflammatory skin disease of unknown etiology seen in children and adults. It is characterized by an annular arrangement of erythematous papules, plaques, nodules or patches. [1] The main clinical variants of granuloma annulare include localized, generalized, papular, umblicated, perforating and subcutaneous. SGA occurs usually in children and consists of deep dermal or subcutaneous nodules. The presence of subcutaneous pseudorheumatoid nodules in a patient with localized GA was the keen observation of Ziegler [2] in 1941.
SGA is also referred to as pseudorheumatoid nodule, deep GA (DGA), subcutaneous palisading granuloma and necrobiotic granuloma. The onset of SGA is usually spontaneous, lesions are benign and self-limited and most patients do not report a recurrence. The factors implicated in the causation of this disease are yet to be clearly elucidated. Proposed mechanisms include physical trauma, infection, immunization, insect bite, diabetes mellitus and aberrant cell-mediated reactions. [3]
The subcutaneous variety of GA is characterized by firm asymptomatic nodules in deep subcutaneous tissues which may be associated with intradermal lesions usually over the anterior pretibial area, ankles, dorsa of the feet, buttocks and scalp. [4] SGA usually involves the subcutaneous tissue with or without involvement of the deep dermis. However, the involvement of more superficial dermal components has been reported in 25% of subcutaneous GA lesions, [5] which may clinically manifest as erythematous to tan discolorations in the surface skin or superficial papules overlying the subcutaneous nodules.
Since SGA occurs almost exclusively in infants and children with maximum frequency between the ages of 3 and 6 years, [6] the present case is unusual because it had onset in adulthood. The presence of acral, isolated, clustered deep granuloma annulare lesions confined to a single digit without classical GA lesions elsewhere is a rare finding. Such a case may mimic multiple osteomas, enchondromas, rheumatoid nodules and giant cell tumor of a tendon sheath. Such cases have rarely been reported in the literature.
Histopathologically, GA is a collagenolytic or necrobiotic non-infectious granuloma wherein palisaded or interstitial type of granulomatous infiltrate develops around a central area of altered collagen and elastic fibers. [7] They are called blue granulomas as the increased mucin in the interstitium imparts a bluish hue. The inflammatory infiltrate in GA comprises of histiocytes and a sparse perivascular infiltrate. Occasional multinucleated giant cells and elastophagocytosis may be seen. Histopathological differential diagnosis includes rheumatoid nodule, necrobiosis lipoidica and epitheliod sarcoma. [7] Histological resemblance to a rheumatoid nodule may frequently pose a diagnostic challenge. A clue to differentiate GA from a rheumatoid nodule may be the presence of prominent mucin and a paucity of foreign body giant cells. [8]
Various treatment modalities are available for the treatment of GA including topical or intralesional steroids, cryotherapy, electrocoagulation, laser destruction, PUVASOL, [9] and topical imiquimod. The use of systemic agents such as systemic steroids, psoralen UV-A, isotretinoin, dapsone, pentoxifylline, hydroxychloroquine, cyclosporine, rifampicin, ofloxacin and minocycline combination, [10] interferon gamma, chlorambucil, potassium iodide, photodynamic therapy, etarnacept, infliximab, adalimumab and efalizumab.
Multiple nodules of granuloma annulare occurring in clusters have been previously described on the scalp of a 4-year-old boy. [11] Isolated and unilateral involvement of a single digit with clusters of nodules of subcutaneous GA in an adult is rare. It frequently poses a diagnostic challenge and commonly mistaken for its clinical simulator rheumatoid nodule. Hence, it is essential to keep in mind SGA as a differential diagnosis when encountered with nodular lesions on acral areas in adults.
| References | | |
| 1. | Mutasim DF, Bridges AG. Patch granuloma annulare: Clinicopathologic study of 6 patients. J Am Acad Dermatol 2000;42:417-21.  |
| 2. | Ziegler E. Rheumatismus nodosus als einzige Manifestation der rheumatischen Krankheit. Arch Kinderh 1941;122:1-6. |
| 3. | Trujillo-Santos AJ, Aguiar-Garcia F, Gonzalez-Hermoso C. Subcutaneous nodules after a cat bite. Arch Intern Med 2001;161:2043-4. |
| 4. | Felner EI, Steinberg JB, Weinberg AG. Subcutaneous granuloma annulare: A review of 47 cases. Pediatrics 1997;100:965-7. |
| 5. | Misago N, Narisawa Y. Subcutaneous granuloma annulare with overlying localized granuloma annulare. J Dermatol 2010;37:755-7. [ PUBMED] |
| 6. | De Aloe G, Risulo M, Sbano P, De Nisi MC, Fimiani M. Subcutaneous granuloma annulare in an adult patient. J Eur Acad Dermatol Venereol 2006;20:462-4. [ PUBMED] |
| 7. | Lynch JM, Barrettm TL. Collagenolytic (necrobiotic) granulomas: Part 1- the blue granulomas. J Cutan Pathol 2004;31:353-61. |
| 8. | Patterson JW. Rheumatoid nodule and subcutaneous granuloma annulare: A comparative histologic study. Am J Dermatopathol 1988;10:1. |
| 9. | Lakshmi C, Srinivas CR. Granuloma annulare - Remission with puvasol. Indian J Dermatol 2010;55:97-8. [ PUBMED]  |
| 10. | Garg S, Baveja S. Generalized granuloma annulare treated with monthly rifampicin, ofloxacin, and minocycline combination therapy. Indian J Dermatol 2013;58:197-9. [ PUBMED] |
| 11. | Pimental DR, Michalany N, Milanes MA, De Abreu M, Alchorne M. Multiple deep granuloma annulare limited to the cephalic segment in childhood. Pediatr Dermatol 2008;25:407-8. |
What is new?
Clusters of subcutaneous granuloma annulare lesions localized and restricted to single digit in an adult is rare and may be misdiagnosed as rheumatoid nodules.
[Figure 1], [Figure 2], [Figure 3] |
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