Approach
Treatment is usually not required, as the condition is self-limiting. There are no specific guidelines for treatment.[36] The following is based on evidence from case reports and general consensus among dermatology specialists.
Localised variant (classic annular rash)
Localised GA is usually left alone unless the patient insists on treatment for cosmetic reasons. Treatment options include cryotherapy, topical corticosteroids with or without occlusion, or intralesional corticosteroids.[37][38][39] Therapy will be dictated by physician and patient preference.
Generalised variant (widespread macular rash)
Treatment may be offered for generalised GA if large areas of the body are affected. Phototherapy is first-line treatment, and most evidence comes from use of psoralen-UV-A (PUVA). However, relapse rates can be high.[40] In this instance, either an extended course of PUVA can be given to try to induce remission or a systemic treatment can be given. Notably, narrow-band UV-B may be effective in some patients.[41]
While there is limited good quality evidence for their use in this indication, hydroxychloroquine and chloroquine are the most widely supported and most often used first-line drugs.[32][42] Hydroxychloroquine is the preferred option as there is less risk of ocular toxicity compared to chloroquine. Results from one retrospective analysis suggest that chloroquine might be beneficial for patients who have previously failed treatment with hydroxychloroquine.[42] Ocular monitoring is required with these drugs.
Systemic retinoids such as isotretinoin are another option. The use of isotretinoin as a second-line treatment is based on historical case reports demonstrating significant improvement.[43] However, there are no recent data to support its use. Isotretinoin is associated with potentially serious adverse effects and requires careful monitoring.[44] In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme (PPP), while in the US, it can be prescribed only through the iPledge system. iPLEDGE: registration scheme for isotretinoin Opens in new window Providers, pharmacies, and patients must register with the system in order to prescribe the drug. Isotretinoin is contraindicated in pregnancy. Women of childbearing age should use additional contraception. Improvement can take up to 3 months.[45] A number of case reports have demonstrated the efficacy of dapsone in the management of generalised granuloma annulare. However, it has more risks and adverse effects associated with its use compared to isotretinoin, but also appears to be more efficacious.[36] It shows an initial good response, but high relapse rate on cessation of therapy.[46] Reticulocyte count and methemoglobin levels should be monitored weekly during therapy with dapsone, owing to risk of haemolytic anaemia.
For recalcitrant disease, many drugs have been tried, including corticosteroids, methotrexate, pentoxifylline, chlorambucil, and ciclosporin.[47] Tumour necrosis factor (TNF)-alpha inhibitors have been effective in studies of a variety of cutaneous granulomatous eruptions, particularly sarcoidosis, but also necrobiosis lipoidica. Case reports and small case series suggest a potential role for TNF-alpha inhibitors, such as adalimumab, in the management of widespread, recalcitrant GA.[48]
Perforating variant (crusted or ulcerated lesion)
Perforating GA may be treated if it is painful, and this can be successfully done with isotretinoin.
Subcutaneous variant (soft nodule)
Concern often arises over the cause of these subcutaneous nodules. Once the diagnosis is established no treatment is required, and the patient can be reassured that it is a benign condition that is likely to resolve spontaneously.
Patch variant (erythematous plaques)
Patch variant is rare and is usually left to resolve. If persistent, treatment approaches can be based on therapy for generalised GA. A trial of topical corticosteroids may be offered. One case series suggests phototherapy may be particularly effective for this variant.[49]
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