​Kembara Xtra - Medicine - Granuloma Annulare

​Kembara Xtra - Medicine - Granuloma Annulare 
A benign skin ailment known as granuloma annulare (GA) is characterized by clusters of skin-colored to erythematous papules that are normally in an annular (ringlike) pattern and are most frequently found on the dorsal surfaces of the hands and feet. Localized, generalized, subcutaneous, patch, and perforating are the five different forms of GA.



GA is a noninfectious granulomatous illness that is rather frequent. There aren't enough population-based research to figure out the incidence and/or prevalence of GA. A single study from 1980 showed that 0.1-0.4% of newly seen patients visiting dermatologists have GA, however primary care settings did not provide comparable descriptive numbers.

Although the majority of lesions go away on their own in 2 years or less, some last for 10 years or longer.
Females outnumber men by a ratio of 1 to 2.5.
In about two-thirds of individuals, symptoms start to appear around the age of thirty. Each subtype's typical age of onset is as follows:
- Age: 30 years old in the area
- Bimodal age distribution, generalized: 10 to 60 years old;
- Subcutaneous: Ages 2 to 14
Patch: older than 30 years
- Perforating: adolescents and children
Subtype distribution:
- 75% localized
- Broadly speaking: 10-15%
- 5% subcutaneous
- Type of patch: 5%
- Perforation rate: 5%


Pathophysiology and Etiology 

GA's etiology is still a mystery. Tumor necrosis factor alpha (TNF-) and interleukin factors 1 and 2 (IL-1 and IL-) are thought to be the mediators of this delayed-type hypersensitivity reaction to an unknown antigen in the derm (2). Lymphohistiocytic infiltrates, collagen degradation, palisading or interstitial granulomatous inflammation, and mucus deposition are distinguishing histopathologic characteristics.
Genetics
There is some proof that there is a hereditary propensity. HLA-Bw35 was found more frequently in two trials in patients with widespread GA. Notably, thyroid dysfunction has also been linked to HLA-Bw35.


Risk Elements 
There have been no definitive risk factors found. GA has been linked to a number of conditions, including diabetes mellitus (DM), autoimmune thyroid disease, dyslipidemia, HIV, Epstein-Barr virus, herpes simplex virus, systemic lupus erythematosus, TB, and hepatitis B and C. Interferon therapy, trauma, sun exposure, insect bites, borreliosis, and malignancies (most frequently lymphoma) have also been linked to the condition.

Prevention 

GA has no known preventative measures.


Accompanying Conditions 

DM: It is debatable whether GA and DM are related.
Early research from the 1980s suggested a potential connection, but more recent case-controlled research has not found any statistically significant links between GA and DM.

 Thyroid autoimmune disease: Thyroid illness and both widespread and localized GA have been related in numerous case reports. In one case-control research, 100 age-matched women with dermatologic conditions other than localized GA were compared to 24 women with localized GA. When compared to people with other non-GA cutaneous diseases, people with localized GA had a substantially higher incidence of autoimmune thyroid illness (12.5% vs. 1%, p =.022).

No clear connection has been found between GA and cancer. 14 case reports and two correlation studies involving individuals who had GA and one or more cancers were found in a study of the literature. The bulk of these cases involved hematologic malignancies, particularly lymphomas.

Dyslipidemia: GA and dyslipidemia may be related. A single case-control research (n = 140) showed that patients with GA had higher levels of hyperlipidemia than controls (79.3% vs. 51.9%, p.001).
HIV: Among GA patients, individuals who also have HIV seem to have a higher likelihood of having the generalized subtype. Twenty (59%) of the 34 participants in a study with GA and HIV had widespread GA.

Note: Both design and power limitations prevent generalizations about relationships between GA and many disorders, including those mentioned above. Therefore, conclusive links between GA and other disorders cannot be drawn in the absence of fresh studies.

Diagnosis 
GA skin lesions are typically asymptomatic.
Particularly in patients with extensive GA, lesions frequently last for months or even years. No matter the subtype, GA typically resolves on its own, but it can reoccur later on without a clear cause.

clinical assessment 

Localized: asymptomatic, flesh-colored or erythematous annular, or arciform plaque that is 5 mm to 5 cm in diameter and has a moderately firm, ropelike border and central clearing. Peripheral to the major lesion, there may be little 1- to 2-mm papules visible. The dorsal sides of the distal upper and lower limbs are the most often affected areas; palm involvement is uncommon. Multiple lesions are frequently present at the time of presentation.
Lesions that are generalized share the same morphology as localized GA lesions but are frequently larger, more numerous (typically >10), persistent for longer periods of time, and more pervasive.
Subcutaneous nodules are hard, non-tender, and tend to spread quickly. They most frequently appear on the scalp and/or the anterior portion of the lower limbs, followed by the upper extremities and buttocks.
Patch: Symmetrically dispersed erythematous macules and patches on the trunk and extremities. There may or may not be the characteristic annular configuration; proximal extremities are frequently involved.
Damaged dermal collagen is protruded onto the skin's surface after perforation. Papules can have a diameter of up to 4 mm and have yellowish umbilication, crusting, or scale.
On the body, lesions are frequently widely dispersed and result in scarring.

Differential Diagnosis Localized: erythema migrans, leprosy, necrobiosis lipoidica, annular lichen planus, pityriasis rosea, tinea corporis
Generalized: erythema migrans, sarcoidosis, lichen planus, cutaneous metastases, and mycosis fungoides (cutaneous T-cell lymphoma).
Rheumatoid nodules are subcutaneous. Molluscum contagiosum, sarcoidosis, and insect bites are perforating.

Initial test results from the laboratory and imaging
The history and physical examination are often sufficient to make a diagnosis; laboratory tests are infrequently required.
To rule out a fungus, skin cells under a microscope using a potassium hydroxide (KOH) preparation may be examined.
As clinically required, take into account laboratory testing to assess concomitant dyslipidemia, diabetes, thyroid disease, HIV, hepatitis B/C, and cancer.
Other/Diagnostic Procedures
Identification of the subtype and confirmation of the diagnosis may be aided by punch biopsy and histologic analysis.
The diagnosis may also be aided by immunohistochemical investigation using the HPR method for CD68/KP-1, a marker for histiocytic differentiation.
Interpretation of Tests
An anuclear dermis with mucin deposition is surrounded by foci of degenerative collagen together with palisading granulomas in a dermal infiltration. Interstitial histologic infiltration between collagen fibers, classic palisading dermal granulomas, and epithelioid tuberculoid and sarcoidal granulomas are examples of histologic varieties.

Management 

GA is a self-limiting condition that will probably spontaneously regress. Following a diagnosis of GA, the clinician's main responsibility is to inform the patient about the disease's normal course and to think about screening for illnesses that might be related to it. The majority of recommendations are based on case reports, case series, and retrospective reviews because no particular treatment has been satisfactorily investigated in dependable randomized controlled trials.


Due to the self-limited nature of the condition, it is the responsibility of the providers to weigh the risks and benefits of the proposed course of action. Medication The trauma caused by biopsy alone can cause lesions to evolve through a process that is unclear. The following treatments have been tried with varying degrees of success in treating the following localized, asymptomatic diseases. The length of therapy is frequently depends on clinical response and is not predetermined.

Primary corticosteroids
Class I or II high-potency topical, with or without occlusion
Triamcinolone intralesional: 2.5 to 5.0 mg/mL concentration. Technique: Place the needle at the raised border of the dermis and slowly inject while removing the needle with adequate volume to start the lesion blanching. Be careful not to poke the needle through the lesion by letting the needle's tip pass through.

Next Line
Pimecrolimus cream: 1% BID; Tacrolimus ointment: 0.1% BID; Chloroquine: 250 mg/day; Hydroxychloroquine: 9 mg/kg/day for 2 months, 6 mg/kg/day for month 3, and 2 mg/kg/day for month 4; Doxycycline: 100 mg/day for 10 weeks; Isotretinoin: 0.50 to 0.75 mg/kg/day; Rifampin:

TNF-inhibitors, such as infliximab 5 mg/kg IV weeks 0, 2, and 6, then variable, or adalimumab 80 mg SC at week 0, and then 40 SC at week 1 and every other week, or etanercept 50 mg twice weekly are examples of treatments that use interferon gamma 1b.


Further Treatments 

Narrowband ultraviolet B (NBUVB), Psoralen ultraviolet A (PUVA), 585–595 nm pulsed dye laser, fractional thermolysis (e.g., YAG fractionated laser), cryotherapy (one 10- to 60-second freeze–thaw cycle), and surgical excision (for subcutaneous GA).

Take Action 
Regular follow-up is not necessary prior to starting treatment. In such cases, follow-up is advised to look for any potential therapy side effects. Patients with generalized GA, those with aesthetic issues, and those whose lesions continue despite conservative therapy should be sent to a dermatologist.


Modification of Lifestyle 
Patients should be informed that GA is a benign, self-limited illness that can last anywhere from months to years before it spontaneously clears itself and returns.
Patients may also find it helpful to know that GA is not thought to have an infectious cause and is not contagious.

The majority of cases (>50%) spontaneously resolve within two months to two years after the disease's beginning, but recurrence—typically at the initial site—is frequent (>40%). Patients under the age of 39 frequently experience shorter illness times.

problems Treatment-related problems are considerably more probable than GA-related complications.

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