Saturday, January 01, 2011
The pathogenesis of granuloma annulare is not known and, for
this reason, therapy is empiric. The effectiveness of therapy of
granuloma annulare (GA) may be difficult to gauge because
spontaneous resolution of individual lesions or the entire disease
process is common.
- Prescribe a superpotent topical steroid to be applied to
lesions in a thin film twice daily. Although GA is a dermal
inflammatory disease, a substantial percentage of lesions will
respond to this therapy within 2-4 weeks.
- In thin-skinned areas such as the neck, tacrolimus ointment
0.1% may be applied twice daily.
- Apply squares of corticosteroid-impregnated tape to lesions for
12-24 hours, or prescribe an intermediate-potency topical steroid
(eg, triamcinolone acetonide 0.1% cream) under plastic wrap or
plastic glove occlusion overnight for 2 to 3 weeks.
- Inject triamcinolone acetonide final concentration 2.5-5.0
mg/cc using a 30-gauge needle into the lesions in the dermis or
subcutaneous tissue. Injections can be repeated very 3-4
In the event that the patient does not respond or lesions
rapidly recur, the following have been tried with some success.
These treatments are usually reserved for patients with symptomatic
generalized or ulcerating disease.
- Systemic retinoids, isotretinoin (40-80 mg daily) and acitretin
(25-50 mg daily) may be attempted.
- Oral or bath PUVA (psoralen plus UVA therapy) may be effective
for generalized lesions. Retinoids and PUVA may be combined
- Hydroxychloroquine 200 mg twice daily or chloroquine 250 mg
- Tranilast 300 mg/day.
- Potassium iodide 5 drops of the supersaturated solution (SSKI)
3 times daily increasing to 10 drops 3 times daily, taken in a
glass of water or citrus fruit juice, is effective in some
patients, although lesions often recur following cessation of
- Prednisone 40-60 mg daily will lead to a rapid improvement in
most cases; however, it is rare for systemic steroid therapy to
induce a significant remission, and in fact most patients have
flares when still on unacceptable daily doses of systemic steroids
(20 mg/day). Prednisone may be used as "rescue" therapy in severely
symptomatic patients awaiting a response from another systemic
- Defibrotide 400 mg/day.
- For refractory, severe cases, cyclosporine 5 mg/kg/day can be
- There may be an association between generalized, extensive GA,
and diabetes mellitus in about 10% of cases. Localized GA may be
associated with autoimmune thyroiditis in about the same percentage
of women. If not recently evaluated, patients with these forms of
GA should have the appropriate evaluations.
- The pitfalls of topical steroids, systemic retinoids, PUVA, and
cyclosporine are described elsewhere.
- The pitfalls of oral potassium iodide therapy include brassy
taste, burning mouth, increased salivation, runny nose, sneezing,
and eye irritation. Salivary gland enlargement may occur. Diarrhea,
gastric upset, anorexia, fever, and depression are reported side
effects. Acne may appear or be exacerbated.