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Granuloma annulareGranuloma annulare

Deba P Sarma, MDDeba P Sarma, MD

OmahaOmaha

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M 63, leftM 63, leftelbowelbow

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Alcian blue at pH 2.5: Increased blue stained stromal mucin

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Diagnosis:Diagnosis:Skin, left elbow, biopsy:Skin, left elbow, biopsy:

-- Suggestive of granuloma annulare.Suggestive of granuloma annulare.

Comment:Comment:

Biopsy shows marked artifact. Dermis shows focal histiocyticBiopsy shows marked artifact. Dermis shows focal histiocyticand giant cell infiltration in between the collagen fibers withand giant cell infiltration in between the collagen fibers with

increased stromal mucin. No necrobiosis or wellincreased stromal mucin. No necrobiosis or well--formedformed

granuloma is noted. Special stains (PAS, AFB) are negative forgranuloma is noted. Special stains (PAS, AFB) are negative for

fungus and acid fast organism. Alcian blue stain at pH 2.5 showsfungus and acid fast organism. Alcian blue stain at pH 2.5 shows

increased stromal mucin. Similar histologic pattern may be seenincreased stromal mucin. Similar histologic pattern may be seen

in necrobiosis lipoidica, rheumatoid nodule, sarcoidosis,in necrobiosis lipoidica, rheumatoid nodule, sarcoidosis,

elastolytic granuloma etc. Correlate clinically.elastolytic granuloma etc. Correlate clinically.

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Granuloma annulareGranuloma annulare

Granuloma annulare (GA) is a benign inflammatory dermatosis of Granuloma annulare (GA) is a benign inflammatory dermatosis of 

unknown etiology.unknown etiology.

Granuloma annulare is relatively common disease that occurs in allGranuloma annulare is relatively common disease that occurs in all

ages, but it is rare in children. F > M.ages, but it is rare in children. F > M.

ClinicallyGA presents as dermal papules and annular plaques.ClinicallyGA presents as dermal papules and annular plaques.It may be localized (most common), generalized or subcutaneous.It may be localized (most common), generalized or subcutaneous.

Most cases of GA resolve spontaneously.Most cases of GA resolve spontaneously.

GA may be associated with Type 1 diabetes mellitus andGA may be associated with Type 1 diabetes mellitus and

hematopoietic malignancies (lymphoma and leukemia).hematopoietic malignancies (lymphoma and leukemia).

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Microscopic:Microscopic:

Early lesions show an interstitial pattern characterized byEarly lesions show an interstitial pattern characterized bysuperficial and deep perivascular lymphocytic infiltratessuperficial and deep perivascular lymphocytic infiltratesand by macrophages scattered between dermal collagenand by macrophages scattered between dermal collagenbundles that are separated by mucin.bundles that are separated by mucin.

Increased number of mast cells may be seen.Increased number of mast cells may be seen.

Mucin in granuloma annulare is hyaluronic acid appearsMucin in granuloma annulare is hyaluronic acid appears

as faintly basophilic stringy material on H&E stain. It canas faintly basophilic stringy material on H&E stain. It canbe confirmed by staining with colloidal iron or Alcian bluebe confirmed by staining with colloidal iron or Alcian blueat pH 2.5.at pH 2.5.

Fully evolved GA lesions and deep subcutaneousGAFully evolved GA lesions and deep subcutaneousGAnodules demonstrate palisaded granulomatous dermatitisnodules demonstrate palisaded granulomatous dermatitisor a septal and lobular panniculitis.Macrophagesor a septal and lobular panniculitis.Macrophages

surround acellular necrobiotic areas in which collagensurround acellular necrobiotic areas in which collagenbundles are thinned with a pale, homogeneous, lightbundles are thinned with a pale, homogeneous, light--blueblueappearance due to the presence of mucin.appearance due to the presence of mucin.