Subcutaneous Annular Granuloma in Children: Diagnosis and Management of a Rare Disease

Background: Granuloma annulare (GA) is a benign granulomatous disease of unknown etiology. In childhood GA presents either in its’ localized type (LGA) or subcutaneous type (SGA). This study aims to evaluate our institution’s management of children diagnosed with SGA.

Methods: We retrospectively reviewed the hospital records of all children diagnosed for SGA over the past 20 years and evaluated all data on disease history, lesion location, patient management and outcome.

Main Results: We identified 23 patients (16 girls) with SGA diagnosis who presented at the median age of 5 years (range 1.5 – 13.5 years). All lesions were nontender, without any signs of inflammation, and located at: lower leg (n=19), foot (n=7), trunk (n=3), upper arm (n=2), forearm (n=2), knee (n=1), and scalp (n=2). Nine patients had multiple lesions. In 8 patients parents reported that trauma preceded lumps appearance. In 15 patients (65%) X-rays were performed to exclude osseous abnormalities. Ultrasound examinations were performed in all patients, and 9 patients received MRI. Surgical intervention was conducted in 12 patients (52%) either by biopsy (n=3) or total excision (n=9), two of which recurred postoperatively at 4 and 5 months to resolve spontaneously 6 months later. In 9 of 11 patients who did not undergo surgery SGA resolved spontaneously. Two patients are still on early follow up. The median time of follow up was 14 months (range 5 – 48 months). In one girl a juvenile arthritis and in another girl a chronic inflammatory bowel disease were diagnosed.

Conclusion: SGA is not an easy to diagnose lesion and many unavailing investigations are performed including surgery. For indolent clinically unsuspicious lumps in children a wait and see period of 6 months might be a good alternative to active investigations and interventions.