Types, causes, diagnosis and treatment of granuloma in children

Granuloma annulare

Granuloma annulare is a benign dermatological disease of an often relapsing nature, in which dense rashes slightly raised above the skin, resembling a ring in shape, appear.
The nodules are usually pink in color, but can be flesh-colored or bluish in color. There are single and multiple. Granuloma annulare of the skin is a fairly rare disease, diagnosed in 0.3% of patients who consult a dermatologist. Most often these are school-age children and young people, less often adults. In men, the disease occurs almost 2 times less often than in women.

General information

Granuloma annulare is a benign, chronic and relapsing progressive skin disease.
The lesions are distinguished by the ring-shaped nodules against the background of destruction of collagen fibers and granulomatous inflammatory reactions. They can occur regardless of gender and age. Granuloma is considered an attempt by the body to limit or isolate an infectious, inflammatory process, or foreign body, possibly through a nonspecific immunological reaction.

Causes of granuloma annulare

The etiology of the disease has not been precisely established, but it is assumed that pathologies of the immune system underlie its development.

Granuloma is not associated with systemic disorders, except in cases of multiple rashes in adults, in whom a disorder of glucose metabolism is often detected.

It is believed that the manifestation of the disease may be a reaction to the following risk factors:

• introduction of tuberculosis vaccine (BCG);
• performing a Mantoux test;
• insect bites;
• exposure to ultraviolet rays;
• overdose of vitamin D;
• skin injuries;
• viral infections;
• tick-borne borreliosis;
• diabetes;
• autoimmune thyroiditis;
• tuberculosis.

Classification

Depending on the location and other features of granulomas, there are:

• Subcutaneous - more often found in children, located on the scalp, near the eyes and on the limbs.
• Plaque - usually occurs in women, they are characterized by the presence of erythematous, red-brown or purple plaques without ring-shaped rims.
• Localized and disseminated - as a result of pathology, a single lesion can form or spread to other parts of the body.
• Perforating - this type of dermatosis is quite rare and is characterized by the presence of plugs in the center of formations and gelatin-like discharge, as well as the formation of larger plaques, crusts and further scarring.
• Interstitial form (with a mucin infiltrate between collagen fibers) and frontal form (there is collagen surrounded by histiocytes).

Histology: front garden form of granuloma annulare

Types and symptoms of granuloma annulare

There are four forms of the disease, differing in clinical picture:

1. Localized is the most commonly diagnosed granuloma (about 90% of all cases, especially in childhood). It is characterized by the appearance of small (up to 5 mm) dense hemispherical nodules of flesh-colored or pinkish color, smooth to the touch. They are arranged in the form of an arc or ring, touching each other. Typically appear on the extensor surfaces of the hands and upper arms, legs and feet. Sometimes the scalp and area around the eyes are affected. Gradually, the lesions increase in diameter, reaching 5 or more centimeters. In the center, the skin may be normal or have a bluish tint. There are no signs of epidermal damage.
2. Subcutaneous granuloma annulare differs in that the nodules form not on the skin, but in the subcutaneous layer. Nodules can be either single or multiple. They appear on the back of the hands, upper arms (up to the elbows), scalp, legs, fingers, and less often in the area around the eyes. This granuloma annulare occurs in children only before the age of 6 years. May recur if removed.
3. Disseminated granuloma is characterized by the appearance of multiple purple rashes of different shapes and sizes on different areas of the skin. The disease is almost always diagnosed in adults; it rarely affects young people. The formations can be scattered and merging, due to which the lesions acquire a multiform character, are rarely located in a ring-shaped position, and symmetry is a typical feature. Disseminated granuloma annulare is prone to a chronic relapsing course. Resistant to standard treatment.
4. The perforating form occurs in only 5% of cases, mainly in children and young adults. Papules appear on the skin, which merge into large plaques. There is a “plug” in the central part of the hearth. When you press on it, the contents of a jelly-like consistency are released. Then the plaque becomes covered with a crust and acquires a relatively flat surface with a slightly depressed center. In its place, atrophic scars may subsequently form.

Available diagnostic methods

At JSC “Medicine” (academician Roitberg’s clinic) near the Mayakovskaya metro station, you can comprehensively examine the health of adults and children. The latest equipment (ultrasound, MRI, CT) and advanced diagnostic methods, specially equipped rooms - everything is there to confirm or refute granuloma annulare in children. In the early stages of development, neoplasms cannot be detected. Symptoms appear when lesions appear on the surface of the epidermis. A diagnostic examination by a dermatologist is carried out when there are complaints of skin changes. Only after this do they turn to laboratory and histological analyzes of skin biopsies from lesions in case of suspicion of deep forms of lesions.

Treatment of granuloma annulare

Since the nodules usually do not cause any discomfort, therapy may not be required. When planning treatment, it is recommended to take into account the tendency of the disease to spontaneously resolve within 2 years. Relapses occur in approximately 40% of cases, however, new nodules can disappear spontaneously.

If formations create an aesthetic problem or are accompanied by atypical manifestations, you should consult a dermatologist. If any skin formations are detected in a child, it should be shown to a doctor.

The doctor decides how to treat granuloma annulare, depending on the form of the disease, its location and prevalence, as well as the age of the patient.

For rapid healing of the skin, external medications can be prescribed. Effective creams and ointments for granuloma annulare contain corticosteroids: hydrocortisone, betamethasone, methylprednisolone, mometasone, clobetasol. During the first 2 weeks, the drug should be applied to the affected areas once a day. Over the next 2-3 weeks - once every two days. In rare cases, intradermal administration of corticosteroid drugs is required.

Additionally, patients are recommended to take oral vitamin E or ascorbic acid and rutin.

If external therapy with glucocorticosteroids does not produce the expected effect, topical calcineurin inhibitors are prescribed in the form of ointments (pimecrolimus or tacrolimus). They should be applied twice daily.

To treat all forms of granuloma in adults (they are not recommended for children), physiotherapeutic methods can be used: ultraviolet irradiation, phototherapy, PUVA therapy.

In cosmetology, cryodestruction is often used to remove nodules. However, most medical specialists do not advise resorting to such technology and note that this method causes progression of the disease, which is manifested by the growth of lesions along the periphery.

Surgical excision of granulomas is not performed due to the nature of the skin lesions.

If necessary, it is worth adjusting blood glucose levels, treating chronic infections and concomitant pathologies.

Pathogenesis

The pathological process can last several months, or even several years. It presumably begins with a lymphocytic immune reaction, leading to the activation of macrophages and degradation of connective tissue, mediated by cytokines , which leads to the formation of a lenticular papule, which has a clearly defined, somewhat atrophic retraction in the central part, which grows with remitting progression, sometimes accelerating, sometimes slowing down in growth .

The granuloma annulare itself is a plaque measuring 5 square cm or more, slightly rising above the surface of the healthy skin and only matching the tone with it in the center. The skin easily gathers into folds, but around the sunken area there is a dense, waxy, shiny burgundy or slightly pinkish ring or crescent, which is not a very wide ridge (up to 2-3 mm). It may consist of individual grayish papules with pinkish rims that are not fused to the underlying layers of skin.

Granuloma annulare plaque

The rings are sharply defined, with their inner edges descending into sunken central areas. Thanks to palpation, a tumor-like neoplasm can be detected in the thickness of the epithelium, which gradually passes into the surrounding integument. In its structure, it has epithelioid cells and fibroblasts, which are surrounded on the periphery predominantly by lymphoid cells, as well as less common plasma cells and mast cells. The location of the round cell infiltrate is along the main course of the vessels, accompanied by the formation of powerful plexuses from argentophilic fibers. The separation of nodes occurs due to trabeculae and collagen fibers. The central parts are pronounced foci of necrosis and destruction of elastic fibers. The walls of the vessels gradually thicken, endothelial proliferation is observed, which can lead to blockage of individual vessels.

Annular granulomas can be located in the deep layers of the skin itself and even in the subcutaneous fat. They are felt as a peculiar type of nodules, reminiscent of dense peas or beans, which do not change the structure of the skin on the surface.

Etiology of the disease

The nature of the disease is varied. There are infectious and non-infectious granulomas, as well as formations of unknown etiology. The first are observed in viral encephalitis, syphilis, typhoid, tuberculosis, rabies and other acute diseases.

Granulomas of the second type occur as a result of dust diseases (asbestosis, silicosis, talcosis, and so on), as well as around foreign bodies or due to drug exposure.

The third group of formations are found in Horton's and Crohn's diseases, sarcoidosis and others.

There are a number of purely granulomatous diseases, including granuloma on the root of the tooth - a disease that can be a consequence of advanced caries. According to microscopic studies, granuloma cells of different etiologies have obvious similarities, therefore, as the difference between formations, it is worth considering the type of tissue in which they develop, the type of pathogen and the state of human immunity.

Causes and development factors

Granuloma annulare is an idiopathic type .

The reasons for the development of pathology remain poorly understood.

Based on research, a list of factors that can provoke such skin damage has been compiled. According to most experts, the main cause of granuloma annulare is a violation of cellular immunity .

factors can provoke the development of pathology :

• consequences of a child's prolonged exposure to the sun (sunburn);
• a specific reaction of the body to manta or other vaccinations;
• negative consequences of insect bites;
• formation of warts on the skin;
• consequences of skin diseases;
• tuberculosis;
• diabetes;
• endocrine diseases;
• disruption of metabolic processes in the body;
• genetic predisposition;
• consequences of skin injuries;
• autoimmune processes in the body.

Recommendations from pediatricians for the treatment of vitiligo in children can be found on our website.