Stjepan Patrun

Suzana Ljubojević Hadžavdić

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45ACTA DERMATOVENEROLOGICA CROATICADear Editor, Granuloma annulare (GA) is an asymptomatic, chronic, and relatively common granulomatous skin condition which presents with annular papules usu-ally slowly progressing into plaques on the extremi-ties and the trunk. It usually presents with non-scaly, erythematous, annular plaques on the distal extrem-ity (1,2). The pathogenesis of GA is still unknown, although a variety of possible factors contributing the disease have been reported, including drugs (3), insect bites, sun exposure, trauma, vaccinations, and viral infections (e.g. hepatitis B, hepatitis C, HIV, Epstein-Barr virus) (1). Several cases in which GA de-veloped on residual skin changes from herpes zoster have also been reported (4).Acta Dermatovenerol Croat                              2020;28(1):45-46                                    LETTER TO THE EDITORUnusual Case of Granuloma Annulare Associated with Diabetes MellitusA 47-year-old woman presented with erythema-tous-livid plaques on the dorsa of her hands and linear and circular lesions on her neck, gradually spreading for the last 4 months prior to admission at our Department (Figure 1a and Figure 1b). She reported excessive thirst and sweating in the last 30 days, but did not consider it significant since it was summer. The patient was otherwise healthy and was not taking any medications. Mycological swabs taken from the dorsal parts of both hands and the neck were negative. Biopsy of the skin changes was con-sistent with GA, showing palisading granulomatous inflammation which surrounded degenerated col-lagen within the dermis. A routine laboratory check revealed increased levels of glucose (23 mmol/L) and HgbA1C, while lipid and thyroid hormone levels were normal. Fasting blood sugar lever was 17 mmol/L. Therapy with topical corticosteroid (betamethasone cream) for skin lesions was initiated and applied two times daily for 2 weeks. The patient was immediately referred to an endocrinologist and insulin therapy was initiated due to diabetes mellitus. Complete re-mission of the skin changes was observed on the fol-low-up visit after 3 months.Figure 1a. Erythematous-livid plaques on the dorsum of the patient’s hands and linear and circular lesions on the patient’s neck. Figure 1b. Linear and circular lesions on the patient’s neck.46There are many clinical variants of GA such as lo-calized, generalized, disseminated, subcutaneous, ar-cuate dermal erythema, and perforating GA (1). The localized form of GA is most common with annular plaques on the distal extremities. In addition to the typical lesions on the dorsal side of both hands, our patient also presented with atypical, circular lesions around her neck. The relationship between GA and systemic diseases such as diabetes mellitus, thyroid disorders, dyslipidemia, and malignancies remains unclear (5). It is also uncertain whether genetic fac-tors influence susceptibility to GA. Familial cases have been documented, but studies investigating the as-sociation between the disease and human leukocyte antigen (HLA) genes have yielded inconsistent results (6). Increased frequency of HLA-B35 in patients with the generalized form has been reported in a few stud-ies (7). GA mostly affects children and young adults, mostly women. Many cases of GA resolve spontane-ously within 2 years, but relapses occur in many pa-tients. Treatment is divided into localized skin thera-pies and systemic therapies (1). High potency topical corticosteroids along with intralesional corticoste-roids are the most common localized treatments (8). Systemic therapy includes corticosteroids, chloro-quine, dapsone, and isotretinoin (1,9). Cryotherapy and UV-therapy can also be used, although with lim-ited efficacy (10). GA is a common idiopathic disorder of the dermis and subcutaneous tissue that can be associated with a variety of underlying conditions such as diabetes mellitus. The relationship between GA and diabetes mellitus is still unknown. Since skin lesions preceded the diagnosis of DM in our patient and complete re-mission of skin changes occurred with induction of insulin therapy, it is important to perform routine laboratory test in every patient.References:1. Wolff K, Goldsmith L, Katz S, Gilchrest B, Paller AS, Leffell D. Granuloma annulare. In: Fitzpatrick’s Dermatology in General Medicine. 7th Edition. New York: McGraw-Hill; 2008. pp. 369-74.2. Na CH, Kim MS, Song SH, Shin BS. Solitary granu-loma annulare: The first case of development on a healthy child’s palm. Ann Dermatol. 2014;26:113-4.3. Cassone G, Tumiati B. Granuloma annulare as a possible new adverse effect of topiramate. Int J Dermatol. 2014;53:259-61.4. Chang SE, Bae GY, Moon KC, DoSH, Lim YJ. Sub-cutaneous granuloma annulare following herpes zoster. Int J Dermatol. 2004;43:298-9.5. Alirezaei P, Farshchian M. Granuloma annulare: re-lationship to diabetes mellitus, thyroid disorders and tuberculin skin test. Clin Cosmet Investig Der-matol. 2017;10:141-5.6. Friedman-Birnbaum R, Gideoni O, Bergman R, Pollack S. A study of HLA antigen association in localized and generalized granuloma annulare. Br J Dermatol. 1986;115:329-33.7. Friedman-Birnbaum R, Haim S, Gideone O, Barzilai A. Histocompatibility antigens in granuloma an-nulare. Comparative study of the generalized and localized types. Br J Dermatol. 1978;98:425-8.8. Volden G. Successful treatment of chronic skin diseases with clobetasol propionate and a hydro-colloid occlusive dressing. Acta Derm Venereol. 1992;72:69-71.9. Looney M, Smith KM. Isotretinoin in the treat-ment of granuloma annulare. Ann Pharmacother. 2004;38:494-7.10. Nisticò SP, Saraceno R, Schipani C, Costanzo A, Chimenti S. Different applications of monochro-matic excimer light in skin diseases. Photomed Laser Surg. 2009;27:647-54.Stjepan Patrun1, Suzana Ljubojević Hadžavdić21School of Medicine, University of Zagreb, Croatia; 2Department of Dermatology and Venereology, Univer-sity Hospital Centre Zagreb and University of Zagreb School of Medicine, Zagreb, CroatiaCorresponding author: Associate Professor Suzana Ljubojević Hadžavdić, MD, PhDDepartment of Dermatology and VenereologyUniversity Hospital Center ZagrebUniversity of Zagreb School of MedicineŠalata 410000 Zagreb Croatiasuzana.ljubojevic@gmail.comACTA DERMATOVENEROLOGICA CROATICALetter to the editor Acta Dermatovenerol Croat     2020;28(1):45-46

Unusual Case of Granuloma Annulare Associated with Diabetes Mellitus

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