*3.2.1 Granuloma annulare*

It is characterized by ringed erythematous plaques with granulomatous inflammation seen histologically. There are four clinical variants of GA-localized, generalized, or disseminated, subcutaneous, and perforating [83].

The localized, commonest variety, nearly three-fourths of all GA cases, is in this group. Lesions are usually present as skin-colored or erythematous papules, without epidermal change, that are often arranged in arciform or annular patterns, usually less than 5 cm in diameter, and enlarge centrifugally [84–86] (**Figure 16**). Subcutaneous and superficial papular lesions may coexist in some patients, particularly in children [84]. The number of lesions may be single or multiple, in equal distribution. The commonest site of involvement is the hands and arms (63%), lower extremity in 20%, trunk alone in 5%, and all extremities affected in 7% of patients. Both sexes are equally affected [84]. Lesions are temporary in 70% of cases. In 51%, clearing happens within 2 years. The age of the patients did not affect the prognosis to any great extent, and usually three-fourths of patients recover [84].

In generalized (disseminated) granuloma annulare, innumerable number of lesions, arranged in symmetrical distribution, presents in any part of the body, but the face and also the palm and sole are usually spared. There may be macules, papules, or nodules [84], arranged in an annular fashion [86]; colors range from skin-tone to red, yellow, or tan. There is controversy about generalized and disseminated GA. In original description, granuloma annulare was defined as

**81**

**Figure 17.**

*(a and b) Generalized granuloma annulare.*

mobile [84, 89].

**Figure 16.**

*Granuloma annulare.*

*Clinical Manifestations of Sarcoidosis and Granulomatous Disorders*

generalized involvement of at least the trunk and the upper or lower extremities [86] (**Figure 17a, b**). It is asymptotic and usually persists for 3–4 years but may persist up to 10 years and recur [84]. The age of onset is bimodal in distribution, with 80% of patients presenting in the fourth to seventh decades and the remainder presenting

Subcutaneous granuloma annulare, also known as pseudorheumatoid nodule, is a self-limiting disorder usually found between the ages of 3 and 6 years, and the sex ratio is 1:1 [84, 87, 88]. They are small, pinkish, asymptomatic, hard-elastic, nodular, isolated lesions, or associated with local annular granuloma. The overlying skin is healthy. Sites include the pretibial region, elbow, forearm, forehead, scalp, and dorsal surfaces of the hands and feet [84] (**Figure 18**). Lesions situated on the head adhere to the periosteum and are fixed with respect to the underlying layers, whereas those on the extremities adhere to the fascia and are therefore

before the age of 10 [84]. Female to male ratio is slightly higher [86].

*DOI: http://dx.doi.org/10.5772/intechopen.92236*

**Figure 16.** *Granuloma annulare.*

generalized involvement of at least the trunk and the upper or lower extremities [86] (**Figure 17a, b**). It is asymptotic and usually persists for 3–4 years but may persist up to 10 years and recur [84]. The age of onset is bimodal in distribution, with 80% of patients presenting in the fourth to seventh decades and the remainder presenting before the age of 10 [84]. Female to male ratio is slightly higher [86].

Subcutaneous granuloma annulare, also known as pseudorheumatoid nodule, is a self-limiting disorder usually found between the ages of 3 and 6 years, and the sex ratio is 1:1 [84, 87, 88]. They are small, pinkish, asymptomatic, hard-elastic, nodular, isolated lesions, or associated with local annular granuloma. The overlying skin is healthy. Sites include the pretibial region, elbow, forearm, forehead, scalp, and dorsal surfaces of the hands and feet [84] (**Figure 18**). Lesions situated on the head adhere to the periosteum and are fixed with respect to the underlying layers, whereas those on the extremities adhere to the fascia and are therefore mobile [84, 89].

**Figure 17.** *(a and b) Generalized granuloma annulare.*

**Figure 18.** *Subcutaneous granuloma annulare.*
