Granuloma annular in children: clinical, therapy

Annular granuloma is a common benign idiopathic granulomatous dermatitis. The disease is usually asymptomatic and resolves itself. In typical cases observed in the first three decades of life and affects women twice as often as men.

The incidence of annular granuloma is estimated at 0.1-0.4% of all dermatological patients.

The cause of the disease is unknown. The greatest importance is given to changes in the immune system. Several authors (8, 12) believes that the annular granuloma is a disease caused by delayed-type hypersensitivity. According to them, as indicated by the detection of fibrin in the lesions, similar to that in the processes caused by delayed hypersensitivity, uninucleate character infiltrates with the presence of activated macrophages and fibroblasts, sometimes communication with sarcoidosis, the disease after tuberculin tests (6). Infringement of cellular immunity (5). Detection in the walls of small vessels IgM and C3, and fibrinogen was the basis for concluding that the annular granuloma is a consequence of vasculitis (3), so changes of collagen treated as secondary. Annular granuloma is often the nature of TB (6), sometimes develops after acute infection in patients suffering from rheumatism. Disease progression was observed after trauma, tick bites, insect, after the sun burns, etc. (11). Found a generalized annular granuloma connection with antithyroid antibodies (9). There is evidence of possible genetic predisposition (3). With regard to general metabolic disorders, including carbohydrate metabolism, then most likely they have a higher value in generalized forms of (2.10). There is a similarity of the ultrastructure of granuloma annular and diabetic lipoid necrobiosis. A possible difference in the pathogenesis of different versions of the annular granulomas may indicate a higher frequency of occurrence in disseminated form in comparison with local histocompatibility antigen Vw35 (4).
Annular granuloma often develops on-site tattooing and scarring, as well as after the warts and herpes zoster, likely as non-specific immune response (9).

Annular granuloma is usually divided into the following clinical forms: localized, subcutaneous, perforating and disseminated.

Localized annular granuloma. Children over 90% of cases are localized form. Usually there is a single seat or a limited number of lesions on the extensor surfaces of the extremities (60% - on the hands and arms, 20% - on the feet and legs). Rare defeat the periorbital region. Dense dermal papules skin color or slightly erythematous usually found in the form of rings or arcs, with the central plot focus remains unaffected. Foci can be distributed on the periphery, partly allowing or recurring in the same place. The epidermis is not affected. The most common form is annular lesions the size of 2-5 cm or more (in rare cases can reach huge sizes), oval, circular or (rarely) of irregular, polycyclic shape with a slightly sunken central part, consisting of small nodular elements rather compact texture, fairly deep-seated in the dermis, smooth, pink-colored sirenevato or normal skin. Manifestations described in the form of rings, embedded in one another, as in erythema multiforme exudative (1). The preferred location - back of the hands and feet. Less commonly, lesions are located in major joints or other parts of the skin.

Subcutaneous granuloma annular. This form is observed almost exclusively in children younger than six years in the form of single or multiple clinically expressed, deep dermal or subcutaneous nodes on the shins, forearms, elbows, back of hands, fingers and especially on the scalp. May be affected and periorbital area, usually the upper eyelid. Nodes on the extremities, usually movable, but are sometimes associated with the fascia. Sites on the scalp, on the contrary, always tightly connected with the periosteum. Approximately 25% of cases occur more typical superficial foci.

Perforating granuloma annular. Develops in about 5% of cases. Usually observed on the hands or fingers, but can be just a localized version of the ring-traumatic granuloma. At least 50% of patients - children or young adults. Papules are the cork in the center secrete gelatinous contents, and then form a crust and foci umbilicate depression in the center. May later develop atrophic hypo-and hyperpigmented scars. The typical clinical picture of disseminated granuloma annular perforating a papule, which develop into larger plaques.

Disseminated annular granuloma. This form occurs in approximately 15% of patients with annular granuloma, rare in children. The vast majority of patients - those over 50 years. Throughout the body there are a group of papules color or shade of purple, but most often affects the distal extremities and trunk. In these cases, multiple lesions, scattered or confluent, which could give homes character mesh, but without any significant tendency to ring-shaped arrangement (11). Polymorphism observed precipitation (7).

Diagnosis of annular granuloma is usually set clinically. Histological confirmation of the diagnosis is often required for subcutaneous granuloma annular. Histology of granuloma annular may give clues to the etiology of the disease. In the epidermis there is little change, except as perforating forms, in the dermis minor changes in the blood vessels (endothelial proliferation), degeneration of collagen okolososudistye foci with necrosis or necrobiosis and mucin deposition, fibrin, surrounded by infiltration of fibroblasts, lymphoid cells, isolated giant cells (tuberculoid structure is rare). Umbert and Winkelmann (12) observed a predominantly mononuclear cell infiltration in 72% of cases, palisadoobrazny type (histiocytes arranged in a palisade) - 25%, epithelioid cell type - 3%. In the later stages - fibrosis. If the perforating form - foci of degeneration of collagen beneath the epidermis to the penetration of necrobiotic masses through the epidermis. Inflammatory cells are activated Th1 cells with the appropriate set of cytokines, suggesting T-cell mediated immune response to specific (but unidentified) antigens. In addition, a study by direct immunofluorescence reveals deposition of IgG and NW around blood vessels in the dermis, which indicates the possibility of immunocomplex vasculitis.

In planning therapy should take into account the tendency to spontaneous annular granuloma resolution. Approximately 75% of the foci of spontaneously regress within 2 years. Although the recurrence rate is around 40%, new sources may also tend to disappear on their own. In addition, the process proceeds without complaint and is extremely benign.

If pockets of painful or disturb the patient can be assigned to topical corticosteroids with moderate or high pharmacological activity every evening for 14 days and then every other night for 2-3 weeks. If possible, the centers should be closed. Local therapy with vitamin E is ineffective. Sometimes a biopsy can lead to spontaneous resolution of the source. As a method of treatment practiced by surface scarification (scoring).

There are a number of possible systemic effects, but none of them is not reliably effective and no it is not recommended for children. The list of possible system events include corticosteroids, dapsone, antimalarial drugs and retinoids, and PUVA therapy, ultraviolet irradiation, phototherapy.

We observed 15 children with a localized form of annular granuloma (9 girls and 6 boys). Age of children: 3 people. - At the age of 3 years, 9 people. - 3-5 years, 3 people - 6-7 years. The disease duration up to one month - in 6 children from 1 month to 1 year - in 9. 12 out of 15 children, and often long-term sick colds. None of the children was not an infringement of carbohydrate metabolism. Mantoux test was positive in only one child. In 5 children observed one source, 10 - two or more. The maximum number of foci - 8 - there was a girl aged five. The preferential localization of pathological elements - the extensor surfaces of the legs and the rear brake (11 children). In 6 patients, foci were located on the hands. Quite often, granulomas were located in the joints: a 5 - to ankle, with 6 - to interphalangeal. On the skin of the trunk elements rashes were only 2 patients. Two children with multiple lesions performed cryosurgery, which led to the progression of the disease, sprawl on the periphery of lesions.

For the treatment of annular granuloma, we used the ointment korikosteroidnuyu fourth generation - clobetasol propionate (Psoriderm, the company "Farmakar"). The drug has a marked anti-anti-allergic effect. Can be absorbed through normal intact skin, allowing deep-seated inflammation of education. Despite the limitations in using Psoriderma in children, we administered it to treat annular granuloma, since the pathological process is fairly deep and 3.1-generation drugs have no clinical effect. In addition, the number of outbreaks usually small and the ointment is applied in a minimum volume, which prevents the development of systemic adverse reactions.

Children, we recommended to put Psoriderm pockets of a once daily (preferably under occlusive dressing) for 2 weeks and then every other day for 2-3 weeks. All patients were treatment was well tolerated. Complications and side effects were recorded. Clinical recovery achieved in 8 patients, a significant improvement - in 3, improved - in 3. The effect of the therapy were observed in 1 patient.

╩ является эффективным и безопасным методом лечения детей с локализованной формой кольцевидной гранулемы. Thus, the use of corticosteroid ointments fourth generation "Psoriderm" is an effective and safe treatment for children with a localized form of annular granuloma.

References:

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2. Hazizov IE status of carbohydrate metabolism in patients with annular granuloma. Vestn. dermatol. and venerol. 1984, 9, 53-57.
3. Dahe MV, Cherney K-J., Lindroos WE Elevated heparin-pricipitate fraction of Plasma in granuloma anulare .- Arich. derm., 1979, 115, 9, 1059-1060.
4. Friedman-Birnbaum R., Haim S., Oideone O., Barzibei A. Histocompatibility antigens in granuloma anulare .- Brit. J. derm., 1978, 98, 4, 425-427.
5. Friedman-Brirnbaum R., Gilhar A., ​​Haim S., Golan DT Leucocyte inhibitoryfactor in granuloma annulare: a comparative study between the goneralized and localized ty ╛ pes .- Acta derm, venererol. (Stokh.), 1983, 63, 3, 242-243.
6. Kakurai M., Kiyosawa T, Ohtsuki M., Nakagawa H.: Multiple lesions of granuloma annulare following BCG vaccination: case report and review of the literature. Int J Dermatol 40: 579-581 (2001)
7. Kansky A. Granuloma annulare disseminatum .- Hautarzt, 1975, 26, 9, 492-494.
8. Kossard S., Winkelmann R. K-Response of generalized granuloma anulare to alkyloting agents.-Arch, derm., 1978, 114, 2, 216-220.
9. Moran J., Lamb J.: Localized granuloma annulare and autoimmune thyroid disease. Are they associated? Can Fam Physician 41: 2143-144 (1995)
10. Muhlemann M. R, Williams DRR: Localized granuloma annulare is associated with insulin-dependent diabetes mellitus. Br J Dermatol 111: 325 - 329 (1984)
11. Stankler L., Leslie I. Generalized Granuloma anulare in a 15-Month-old-Infant-Dermatologica, 1976, 153, 3, 202.
12. Umbert P., Winketlmann R. K-Granuloma anulare and sarcoidosis. Brit. J. derm., 1977, 97, 481-486.

EA LEVONCHUK