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Table of Contents
LETTER TO THE EDITOR
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 79-81

A case of generalized granuloma annulare with diabetes mellitus: Regressed with antidiabetic therapy


Department of Dermatology, BYL Nair Charitable Hospital and TNMC, Mumbai, Maharashtra, India

Date of Submission02-May-2020
Date of Decision05-May-2020
Date of Acceptance09-Jun-2020
Date of Web Publication17-Sep-2020

Correspondence Address:
Dr. Hanamant Gadade
Department of Dermatology, BYL Nair Charitable Hospital and TNMC, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJD.TJD_43_20

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How to cite this article:
Pathave H, Barve V, Gadade H, Nayak C. A case of generalized granuloma annulare with diabetes mellitus: Regressed with antidiabetic therapy. Turk J Dermatol 2020;14:79-81

How to cite this URL:
Pathave H, Barve V, Gadade H, Nayak C. A case of generalized granuloma annulare with diabetes mellitus: Regressed with antidiabetic therapy. Turk J Dermatol [serial online] 2020 [cited 2020 Oct 26];14:79-81. Available from: https://www.tjdonline.org/text.asp?2020/14/3/79/295261



Sir,

Granuloma annulare (GA) is a benign necrobiotic granulomatous dermatosis of unknown cause, presenting as localized, generalized, perforating or subcutaneous lesions.[1],[2]

Diabetes has been reported to occur in up to 20% cases of GA.[3] We present a case with diabetes mellitus (DM) that was diagnosed while the patient was being investigated for generalized GA (GGA), and his lesions improved after institution of treatment for DM.

A 65-year-old male presented with multiple itchy skin-colored raised lesions on the trunk and extremities of 1-month duration. There was no prior history of drug intake or insect bite hypersensitivity.

Cutaneous examination revealed multiple, well-defined, skin-colored to slightly erythematous papules and nodules on the extremity [Figure 1]a, back [Figure 1]b, and abdomen. Few of the lesions showed central umbilication and crusting. General and systemic examinations were within normal limit.
Figure 1: (a) Multiple, skin-colored, shiny papules with smooth surface on the inner aspect of the left upper extremity. (b) Multiple, skin-colored to hyperpigmented papules with central umbilication and crusting on the back. (c) Palisading granuloma in the superficial and mid dermis around the focus of mucin deposition and necrobiosis (H and E, ×10). (d) Mucin within the center of palisaded granuloma (Alcian blue, ×40). (e and f) After 3 weeks of antidiabetic therapy, the papular lesions completely resolved with residual hyper-pigmentation

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We considered differential diagnoses such as perforating dermatoses, prurigo nodularis, and GA. The patient was asked to get investigations, especially blood glucose, done.

The fasting blood sugar was 250.15 mg/dl and postprandial blood sugar was 409.19 mg/dl. Biopsy showed palisading granuloma with central collagen degeneration [Figure 1]c. An Alcian blue stain showed mucin at the center of granuloma [Figure 1]d. Hence, we diagnosed the case as a GA.

The patient was given oral metformin 500 mg twice daily with glimepiride 2 mg once daily and antihistaminic.

After 3 weeks of his follow-up, we noticed that his blood sugar level became apparently normal and surprisingly, almost all GGA lesions also subsided, leaving behind postinflammatory hyper-pigmentation [Figure 1]e and [Figure 1]f. There was no recurrence at 9 months of follow-up.

GA was described by Calcott Fox in 1895 and named by Radcliffe Crocker in 1902. It is a benign, inflammatory disorder of unknown etiology.[2]

How DM triggers GA is unknown. The increased serum glucose level or the resistance of insulin may change the structure of dermal blood vessels. Another possibility is that it can trigger the disease onset by damaging the structure of dermal collagen.

GGA in diabetes presents as a diffuse papular eruption, with pruritus being the prominent complaint. It differs from the localized form by a later age of onset, protracted course with only rare spontaneous resolution, poor response to therapy, and increased prevalence of human leukocyte antigen Bw 35.[4]

Most cases of GA resolve spontaneously. Though natural resolution is a possible mechanism, biopsy as a triggering factor for resolution cannot be ruled out. Muzeyyen etal.[5] noted that GGA lesions regressed after the regulation of serum glucose level with antidiabetic therapy and contributed to the information of relationship between GA and DM in the etiopathogenesis of GA.

Various methods are used in the treatment of GA [the treatment algorithm figure is depicted in [Figure 2].
Figure 2: Treatment algorithm figure

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Although we cannot exclude the possibility of spontaneous regression of the lesions of GA in our patient, and the effect of biopsy-induced trauma on the disease course, we believe that the lesions regressed by instituting antidiabetic therapy, as the lesions were persisting and deteriorating for 1 month prior to the patient presenting to us.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cohen PR, Carlos CA. Granuloma annulare mimicking sarcoidosis: Report of patient with localized granuloma annulare whose skin lesions show 3 clinical morphologies and 2 histology patterns. Am J Dermatopathol 2015;37:547-50.  Back to cited text no. 1
    
2.
Burns DA. Necrobiotic disorders. In: Burns T, Breathnach S, Cox NH, Griffiths C, editors. Rook's Text Book of Dermatology. 8th ed. Oxford: Wiley-Blackwell; 2010. p. 60.1-12.  Back to cited text no. 2
    
3.
Garg S, Baveja S. Generalized granuloma annulare treated with monthly rifampicin, ofloxacin, and minocycline combination therapy. Indian J Dermatol 2013;58:197-9.  Back to cited text no. 3
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4.
Friedman-Birnbaum R, Haim S, Gideone O, Barzilai A. Histocompatibility antigens in granuloma annulare. Comparative study of the generalized and localized types. Br J Dermatol 1978;98:425-8.  Back to cited text no. 4
    
5.
Muzeyyen G, Secil S, Oguzhan K, Ulker G, Murat D. A case of generalized granuloma annulare that contributed to the diagnosis of diabetes mellitus and regressed with antidiabetic therapy. Turkiye Klinikleri J Dermatol 2009;19:23-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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