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Case Report

Papular granuloma annulare of palms and soles: case report of a rare presentation.

[version 1; peer review: 2 approved]
PUBLISHED 30 Jan 2014
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Abstract

We report the case of a 44-year-old Indian male patient who presented with mildly tender isolated papular lesions confined to the palms of the hands and soles of the feet. The histopathology was characteristic of granuloma annulare. There was an excellent response with 4-week treatment with a potent topical steroid ointment and no recurrence was reported at the follow-up one year later. This report is interesting because of the rare presentation of a common disease.

Introduction

Granuloma annulare (GA) is a relatively common benign inflammatory disorder characterized clinically by dermal papules and annular plaques. First described by T. Colcott Fox1, it occurs in all age groups and the precise etiology remains unknown. A number of clinical variants have been described in the literature but lesions localized to palms and soles are rare1,2. Correlation with histopathological findings, including hyperkeratosis, presence of foci of necrobiosis (fragmented collagen), interstial lymphohistiocytic infiltrate in a palisading fashion, and increased mucin deposition, are important for diagnosis of such lesions. We describe a rare case of the papular variant of granuloma annulare with isolated involvement of the palms and soles.

Case report

A 44-year-old Indian man presented with multiple, slightly painful, raised lesions over the palms and soles that had been present for 3 months. The patient reported having sustained an insect-bite a few weeks prior to the eruption. The patient was a farmer by occupation. His past medical history was insignificant with no history or symptoms suggestive of hypertension, diabetes mellitus, chronic obstructive pulmonary disease or any nutritional deficiencies. He was a non-smoker and reported no relevant family history.

Clinical findings: Cutaneous examination revealed multiple mildly tender dusky red-colored papules over both palms and the medial aspects of both soles (Figure 1a and b) with truncal sparing.

f3046d85-3daf-4b0f-ba1d-ae557c67f4f5_figure1.gif

Figure 1. Morphology of cutaneous lesions.

Multiple tender dusky red-colored papules and plaques over (a) both palms, and (b) medial aspect of both soles.

Diagnostic tests: Hematological and biochemical investigations including a complete hemogram, plasma glucose levels (fasting and post prandial), liver and renal function tests were within normal limits except for a raised Erythrocyte Sedimentation Rate. Serum angiotensin converting enzyme (ACE) levels and serum calcium and phosphate levels we re also normal. Serology for HIV and VDRL tests were negative. Chest radiograph was unremarkable and Mantoux test was negative. Histological examination was done from a 3 mm sized skin biopsy specimen taken from the palm and stained with hematoxylin and eosin (H & E). It revealed hyperkeratosis, acanthosis, superficial as well as deep perivascular mixed infiltrate of lymphocytes, histiocytes and neutrophils in the dermis, over a background of incomplete collagen degeneration, with interspersed mucin (Figure 2). Based on the clinical and histopathological features, a diagnosis of the papular variant of granuloma annulare localized to the palms and soles was made.

f3046d85-3daf-4b0f-ba1d-ae557c67f4f5_figure2.gif

Figure 2. Cutaneous biopsy findings.

Histopathology from the palmar lesion revealed hyperkeratosis, acanthosis, superficial and deep perivacular lymphohistiocytic infiltrate (highlighted by red horizontol arrow) with few neutrophils scattered in the reticular dermis, in a background of incomplete collagen degeneration and interspersed mucin (highlighted by two straight black arrows in the left lower aspect). (HE staining, 100×).

Treatment and follow up

The patient was counselled regarding the benign nature of the disease and started on a twice daily application of a potent topical corticosteroid (clobetasol propionate 0.05%) ointment. This completely resolved the papules within 4 weeks (except for mild post-inflammatory desquamation) with no recurrence reported at the follow up visit one year later (Figure 3).

f3046d85-3daf-4b0f-ba1d-ae557c67f4f5_figure3.gif

Figure 3. Treatment response.

Treatment response with 4 weeks of treatment with potent topical corticosteroid ointment – (a) palmar lesions before treatment, (b) palmar lesions after treatment with almost complete clearance of lesions and mild desquamation, (c) plantar lesions before treatment, and (d) cleared soles with only mild erythema and focal desquamation.

Discussion

GA, a common benign skin condition of unknown etiology has many clinical variants including localized, generalized, papular, umblicated, subcutaneous, perforating, follicular, pustular, and actinic granuloma. The localized variety is the most common and presents with skin-colored to violaceous papules in an annular configuration, most commonly over the dorsal side of the feet, ankles, lower limbs and wrists. In the generalized variety (encountered in only 15% cases), lesions are more widespread, consisting of papules as well as plaques, and involve the trunk, neck, extremities, face, scalp, palms and soles3. Therefore, while palms and soles are frequently involved in the less common generalized variant, they are usually spared in the localized papular variant, which typically affects the dorsa of hands and feet. The subcutaneous variety of GA is characterized by firm asymptomatic nodules in deep subcutaneous tissues, usually over the anterotibial plateau, ankles, dorsa of the feet, buttocks and scalp4. The rare perforating variety presents with superficial umblicated papules with keratotic crusts, usually present over the dorsa of hands and fingers, trunk or extremities5. When GA involves the palms and soles, it may present with tender erythematous annular plaques (usually as a part of generalized variant), subcutaneous nodules or perforating lesions6. In our case, the patient had localized papular GA involving the palms and soles, a rare presentation, with only few cases reported in literature611. The largest case series was a clinicopathological description of seven cases with palmar lesions of GA by Gutte et al.6. They reported a palisading and interstitial pattern on histopathology, which is typical of GA lesions elsewhere on the body. Perineural granuloma, perieccrine granuloma and elastophagocytosis with mucin deposition were additional findings in some cases6.

A number of disorders can clinically and histologically mimic GA, including interstitial granulomatous dermatitis with arthritis, palisading neutrophilic and granulomatous dermatitis, rheumatoid nodule and granulomas of Churg Strauss disease3. Erythema elevatum diutinum, acral Sweet’s syndrome, dermatofibroma and drug-induced granulomatous eruptions are other conditions which should be considered in a patient presenting with painful acral papules6,12.

GA is considered to be an immune-mediated reaction, more specifically, a delayed type IV hypersensitivity response, but the exact etiology remains unknown. Various precipitating factors have been proposed, including trauma, insect bites, viral infections, sun exposure, and medication1. Our patient reported an insect bite that had occurred a few weeks prior to the eruption.

Treatments that have been proposed for GA include topical or intralesional steroids, cryotherapy, electrocoagulation, laser destruction, phototherapy, topical imiquimod, and systemic agents such as antimalarial drugs, corticosteroids, isotretinoin, dapsone, cyclosporine niacinamide, vitamin E, pentoxyfylline and infliximab13. In our patient, treatment with a potent topical corticosteroid (clobetasol propionate 0.05%) ointment resulted in complete resolution in 4 weeks. The patient did not develop lesions elsewhere, nor did he report any recurrences at the one-year follow up. Hence, the patient did not require any systemic drug treatment for his GA to date.

Consent

Written informed consent for publication of the clinical details, and clinical images, was obtained from the patient.

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how to cite this article
Sonthalia S, Arora R, Sarkar R and Khopkar U. Papular granuloma annulare of palms and soles: case report of a rare presentation. [version 1; peer review: 2 approved]. F1000Research 2014, 3:32 (https://doi.org/10.12688/f1000research.3-32.v1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 30 Jan 2014
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27
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Reviewer Report 04 Feb 2014
Mohamed Badawy Hassan Tawfik Abdel-Naser, Faculty of Medicine, Ain Shams University, Cairo, Egypt 
Approved
VIEWS 27
This is a well written and interesting case report. There are few remarks.
 
Abstract:
  • The phrase “palms and soles” is better than “palms of the hands and soles of the feet”.
Cutaneous findings:
  •  One of the violaceous palmar papules shows a central umblication! Is
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Abdel-Naser MBHT. Reviewer Report For: Papular granuloma annulare of palms and soles: case report of a rare presentation. [version 1; peer review: 2 approved]. F1000Research 2014, 3:32 (https://doi.org/10.5256/f1000research.3725.r3485)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
30
Cite
Reviewer Report 30 Jan 2014
Maxwell Fung, Department of Dermatology, University of California, Davis, Sacramento, 95816, USA 
Approved
VIEWS 30
The authors have submitted an interesting, relatively novel, and clinically relevant case of acral papular granuloma annulare (GA).

I cannot independently verify the diagnosis of GA based on the photomicrograph provided. An image obtained at higher magnification may be required to ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Fung M. Reviewer Report For: Papular granuloma annulare of palms and soles: case report of a rare presentation. [version 1; peer review: 2 approved]. F1000Research 2014, 3:32 (https://doi.org/10.5256/f1000research.3725.r3434)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 30 Jan 2014
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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