Disseminated Granuloma Annulare: What to Do When Systemic Therapy Has Not Achieved Clearing

Clinical scenario

Disseminated (generalized) granuloma annulare is characterised by widespread skin involvement, defined as 10 or more lesions. This form affects approximately 15 percent of all patients with granuloma annulare and often proves more resistant to treatment than the localized variant.

Prior systemic therapy — goals not reached

The previous treatment step for disseminated granuloma annulare involved systemic therapy — potentially including dapsone, a retinoid (isotretinoin or etretinate), an antimalarial (hydroxychloroquine or chloroquine), cyclosporine, niacinamide, PUVA therapy, fumaric acid esters, or a topical calcineurin inhibitor (tacrolimus or pimecrolimus) — undertaken in consultation with a dermatologist. When those options do not achieve resolution or clearing of the skin lesions, further escalation is warranted.

Next-line approach

For recalcitrant disseminated granuloma annulare that has not responded to the above systemic options, a biologic agent — specifically a tumor necrosis factor α inhibitor administered by intravenous infusion — has demonstrated a positive outcome. The complete protocol, including agent selection, infusion schedule, and course duration, is available in the full regimen.

Treatment goal: Clearing of the granuloma annulare skin lesions.

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References

Disseminated or generalized granuloma annulare is similar to the localized variant but is more widespread, having 10 or more lesions (Figure 3).

Approximately 15 percent of all patients with granuloma annulare will have more than 10 lesions (i.e., disseminated granuloma annulare).

Infliximab (Remicade), a tumor necrosis factor α inhibitor, demonstrated a positive outcome in a patient with recalcitrant disseminated granuloma annulare.

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