Abstract

Granuloma annulare is a self-limited dermatosis characterized by annularly arranged erythematous, non-scaly papules or plaques, favoring hands, feet, wrists or ankles of young adults. However, we present a unique case of a subcutaneous variant of granuloma annulare in a 7-year-old Caucasian female, who had multiple chronic lower leg nodules. She described them as skin-colored mobile nodules on the shin, occasionally tender on palpation, without redness, drainage or pruritis. There was no history of streptococcal throat infection. Immunizations were up to date. The systemic review was negative for oral and genital ulcerations, joint pains, photosensitivity, or Raynaud's phenomenon. Physical exam was unremarkable except for numerous, firm, mobile, deep subcutaneous nodules on the lower extremities bilaterally. The nodules lacked the annular appearance or scaling and had no distinct color. Clinically the differentials included deep granuloma annulare and erythema nodosum. A 4 mm punch biopsy was performed. Microscopy showed the proliferation of histiocytes in the deep reticular dermis with central necrosis. Alcian blue stain was positive for mucin. Acid-fast stain and PAS stain were negative for infectious organisms or fungal hyphae. The findings were consistent with deep granuloma annulare. Pathologically differentials comprise necrobiosis lipoidica, rheumatoid nodule and epithelioid sarcoma. Our case is unique considering its distinct clinical presentation with multiple, bilateral involvement of non-pruritic subcutaneous nodules without ring arrangement. This is unlike the usual solitary, painless mass in the subcutaneous variant. It is important to recognize because they are self-limiting and proper diagnosis can avoid extensive medical workup when systemic symptoms are absent.

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