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Mark V. Dahl, MD

Arch Dermatol. 2007;143(7):946-947.

Granuloma annulare is a peculiar skin disorder of unknown cause.¹ Asymptomatic, annular, skin-colored to violaceous papules and plaques mysteriously erupt on nonfacial skin, usually without any obvious cause. A loose collection of histiocytes surrounds or infiltrates a more amorphous and rather acellular zone of degenerated connective tissue and mucin. Often the disorder resolves with or without treatment.

Perhaps inflammation is aberrant,^2-4 and the nature of inflammation differs from person to person, based on some genetic perturbation. Perhaps an "ordinary" event such as a tuberculin skin test, trauma, infection, insect bite, or sun exposure starts an inflammation that deviates from its usual path and morphs into a persisting necrobiotic granuloma instead of resolving. Based on this hypothesis, one might predict that patients with granuloma annulare would develop other bizarre inflammatory disorders or odd sequelae, even many years later. Perhaps they might even die from an odd disease or disorder.

Methods
To test this prediction, we identified the Mayo Clinic records of patients with granuloma annulare. The institutional review board approved a retrospective medical chart review of these records in a study designed to survey the development of subsequent disease among affected patients. The study was a qualitative pilot study. No attempt was made to age- or sex-match subjects.

The study group consisted of 32 patients with granuloma annulare seen at Mayo Clinic between 1950 and 1970. All subjects had follow-up visits at Mayo Clinic for at least 20 years. The charts were screened for unusual diseases and for diseases related to connective tissue, odd inflammations, or unusual diseases. There were 21 female and 11 male subjects. The average age at diagnosis was 48 years (age range, 4-58 years). Only 3 were children younger than 12 years. The mean follow-up was 35 years (follow-up range, 20-53 years).

Results
The patients seemed remarkably healthy, even in old age. No patient had granuloma annulare at last examination. Interesting comorbidities are listed in the Table. Most patients with conditions or diseases had only ordinary ones such as hypertension, hyperlipidemias, degenerative joint disease, and atherosclerosis.

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table. A Sample of Other Diseases Found in Patients Who Had Granuloma Annulare

In summary, patients who develop granuloma annulare usually heal, remain remarkably healthy, and do not ordinarily develop other odd diseases.

AUTHOR INFORMATION
Correspondence: Dr Dahl, Department of Dermatology, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259 (dahl.markv{at}mayo.edu).

Financial Disclosure: None reported.

Funding/Support: This research was supported by the Mayo Clinic Arizona.

REFERENCES
1. Dahl MV. Granuloma annulare. In: Freedberg IW, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, eds. Dermatology in General Medicine. 6th ed. New York, NY: McGraw Hill; 2003:980-985. 2. Dahl MV. Speculations on the pathogenesis of granuloma annulare. Australas J Dermatol. 1985;26(2):49-57. FULL TEXT | PUBMED 3. Dahl MV, Callen JP. Granuloma annulare. In: Thiers BH, Dobson RL, eds. Pathogenesis of Skin Disease. New York, NY: Churchill-Livingstone; 1986: 317-330.4. Cherney KJ, Lindroos WE, Goltz RW, Dahl MV. Leukocyte function in granuloma annulare. Br J Dermatol. 1979;101(1):23-31. FULL TEXT | ISI | PUBMED