The clinical presentation of GA varies widely. The term annulare refers to the round or arciform shape of the lesions, which are often erythematous, dome-shaped papules that form a circle with central clearing (hence its frequent diagnosis as ringworm) or faintly erythematous depression at the center. Lesions may be asymptomatic or pruritic.

Diagnosis is usually made based on clinical presentation but can be confirmed with a punch biopsy if there is any doubt. Histologically, there are two patterns of GA, palisading and interstitial (such as interstitial GA). The latter should not be confused with interstitial granulomatous dermatitis. A KOH slide can help differentiate GA from tinea corporis, which has scale. Serologies can be ordered if syphilis is considered.

Localized GA is usually not treated unless it concerns the patient due to appearance. Treatment is provided mainly for cosmetic purposes
and often with less than optimal results. First-line treatment includes high-potency topical corticosteroids (TCS) with or without occlusion, intralesional (IL) corticosteroid injections into the elevated portions of the lesions with triamcinolone acetonide (depending on location), or cryotherapy. Risks from these treatments include atrophy and scarring. Off-label use of tacrolimus, pimecrolimus, and imiquimod has been reported to have some efficacy. Second-line treatment that may be used in dermatology for severe localized GA includes systemic agents such as isotretinoin, antimalarials, cyclosporine or dapsone.

Treatment for generalized GA is difficult and the patient should be referred to a dermatologist for photochemotherapy using oral psoralen and ultraviolet light A (PUVA), CO2 laser, or systemic agents.

Most lesions resolve spontaneously after several months to several years (50%-75% clear within 2 years) but may recur. The generalized form may last for an extended period of time. GA does not typically result in scarring but may occur secondary to treatments.

Refer to dermatology if the diagnosis is unclear or when lesions are unresponsive to first-line treatment. Clinicians providing IL triamcinolone should be experienced to minimize side effects.

Educate patients about the disease; provide anticipatory guidance and reassurance. They should be alert for side effects to medications and treatments, seeking appropriate intervention if they occur. Patients may become anxious if they develop multiple lesions, the lesions involve several areas, and/or lesions expand.

Patients are often evaluated by a dermatologist and may be monitored occasionally since GA is benign and self-limiting. Patients with generalized GA should have regular checkups and be monitored for side effects of immune-modifying medications. Any signs or symptoms of infection should be evaluated immediately and care coordinated with a dermatologist.

As the name implies, lesions present as asymptomatic annular plaques on sun-exposed areas. Lesions may be flesh or pink color with classic GA morphology (Figure 20-3).

As with GA, diagnostic tests are usually not indicated but may be necessary to confirm the diagnosis.

First-line treatments for actinic granulomas are similar to GA, but the response is usually poor. Other treatments, such as phototherapy and antimalarials, have been reported. Sun protection is important to prevent new lesions.

Most lesions resolve spontaneously after several months to several years. Lesions may recur or spread secondary to sun exposure. Actinic granuloma does not usually cause scarring. Secondary scarring may occur with atrophy from IL corticosteroid injections.

Refer to dermatology if the diagnosis is unclear, lesions are atypical, or for second-line therapy. Patients may desire consultative care for cosmetic treatment.

Follow-up care of patients with actinic granuloma is same as GA. Emphasis should be placed on patient education for sun protection to avoid the development of new lesions.

Foreign-body granulomas usually present as an inflamed nodule or plaque usually accompanied by tenderness. In the early stage, there can be purulence. In time, the chronic lesion may become firm, sclerotic, or scarred (chronic stage) (Figure 20-4).

Accurate diagnosis depends on history taking. Biopsy may be helpful, and an x-ray may identify the foreign body if it is substantial in size and radiopaque. A punch biopsy may be curative.

Management depends on symptoms and patient preference. Surgery may be necessary for removal of the foreign body. Lasers have been used for tattoo removal with variable results.

A foreign-body granuloma is not life- or limb-threatening but may limit function, create annoyance, or be cosmetically displeasing. Complications from surgical removal include risk of infection and scarring.

Foreign-body granulomas of the hands, feet, or digits may require consultation with a specialist such as a hand surgeon or orthopedic surgeon. Cosmetically sensitive areas may require consultation with a plastic surgeon or dermatologist.

Emphasis should be placed on prevention of new lesions from repeated exposure. Follow-up with their primary care provider (PCP) or specialist should be as needed.

Skin lesions start as small, violaceous, round or oval, sharply defined patches or thin plaques favoring the anterior lower legs (Figure 20-5). Then slowly, the lesion expands in size, with the borders remaining red and center evolving into a waxy yellow/brown color. The surface is often shiny with telangiectasias present (Figure 20-6). Lesions may
be asymptomatic or can have tenderness, pruritus, itching, paresthesias, or numbness. Trauma in the area frequently leads to nonhealing ulcers.

Lesions of NL are often very resistant to treatment. The focus of therapy should be to prevent leg ulcers and to heal them quickly should they develop. Corticosteroids are the mainstay of treatment for NL. Potent TCS used daily for 2 to 4 weeks is recommended for active areas (usually borders) of large, thick plaques. It provides little improvement and may even cause a worsening of atrophy in “burnt-out” lesions of NL. IL triamcinolone acetonide (10 mg /mL), which can be diluted with lidocaine or sodium chloride to reduce risk for atrophy, may be used for smaller lesions or injected into their erythematous border. Oral corticosteroids can be effective in healing ulcerations. The benefits and risk of this systemic therapy should carefully be considered in diabetic patients. Ulcerations from NL have been reported to respond to off-label treatment with pentoxifylline, as well as aspirin and dipyridamole. Other medications include cyclosporine, tacrolimus ointment 0.1%, PUVA, and hydroxychloroquine. Skin grafting may be necessary for extensive, nonhealing ulcers.