Granuloma annulare is a chronic inflammatory skin disease consisting of a rash with reddish bumps arranged in a circle or ring. Granuloma annulare is often of unknown etiology most commonly presenting on the hands and feet and consisting of asymptomatic to mildly itchy, flesh-colored to erythematous annular plaques. Granuloma annulare is a benign, asymptomatic, self-limited papular eruption found in patients of all ages. This benign cutaneous inflammatory disease usually has spontaneous improvement in two years in 50% of cases, but there is recurrence in 40% of patients.
Incidence, how common is it?
Localized ranuloma annulare most often affects children and young adults. It is slightly more common in girls. The condition is usually seen in otherwise healthy people. Occasionally, it may be associated with diabetes or thyroid disease. Generalized granuloma annulare occurs more commonly in older patients.
Granuloma annulare cause
There are a number of conditions that are associated with it. The following is a list:
Chemotherapy drugs that interfere with the immune system.
Drug reaction - One case report indicates amlodipine as a cause. Amlodipine is used alone or in combination with other medications to treat high blood pressure and chest pain (angina). It is in a class of medications called calcium channel blockers. Allopurinol is another medicine that can rarely cause granuloma annulare. There may be other drugs that induce this skin condition that we may not be aware of yet and possible ones to look into in the future include Zocor, Fosamax, levoxyl and topiramate.
Hepatitis B and C infection
Leukemia and Lymphoma
Thyroid disease including autoimmune thyroiditis
Vaccination with tetanus, BCG.
Granuloma annulare skin lesions have developed in patients during anti-tumor necrosis factor (TNF) therapy.
SSRI antidepressants may be a rare cause
Q. I was diagnosed with granuloma annulare several years ago. I have spots on my hands and mostly on my neck. I have been taken Celexa and Ziac for about 5 years now. Do you think that those medications can be the cause?
A. Celexa is an antidepressant. Ziac is a combination of Bisoprolol and hydrochlorothiazide for hypertension. As of 2013, we could not find any reports in the medical literature that these two prescription medications cause granuloma annulare. However, as part of the causative agents for this skin condition, many drugs are part of the differential diagnosis.
Q. I get this on my hand and neckÖI too take an antidepressant for anxiety, Paxil ( a good 15 years now). I seem to get a dot maybe 2 after sun exposure that of course turn to a ring, gets biggerÖand eventually the ring breaks and seems to ďmoveĒ and after a year or 2 is gone. I have only gotten this on the top of my hands and neck.
Photodermatol Photoimmunol Photomed. 2012. Granuloma annulare photoinduced by paroxetine.
Q. I am a 60 year old woman, healthy and active. Three
years ago I started with GA and it is all over my trunk and other areas. I found
your site about GA and I wanted to know if there is any correlation among GA and
hormones. Generalized GA are reported by women around my age, I start to think
that lack of hormones are associated with it. Any studies about it?
A. There may be some relation to hormones and granuloma annulare and hormones, but I am not certain. Thyroid diseases have been suspected, but I am not sure how it is related to estrogen or progesterone or testosterone, if any.
Natural Treatment for Granuloma
Annulare - How to Manage your condition
At this time there is little knowledge on dietary or nutritional options for the treatment of granuloma annulare. The first option is to make sure any of the prescription drugs you may be taking is not causing the condition. Certain drugs can have unusual side effects, either alone or in combination with other drugs. Perhaps if some of the drugs you are taking could be stopped for a couple of months unless they are absolutely necessary.
Second, make sure you have a full checkup to rule out any conditions listed above that could be causing the skin problem. This would include a routine blood tests plus evaluation for autoimmune conditions. For instance, make sure you do not have diabetes, a thyroid problem, or an infection. Third, consider improving your diet to reduce sugar and sweets, and increase your intake of fresh vegetables and eat more salmon, halibut, tuna, sardines, and fish. See diet for suggestions. Also, improving sleep patterns can help your immune system. I am not aware of dietary supplements that are effective for this condition.
Lastly, if all else fails, some of the standard medical options listed below could be tried. Often, GA is a self-limited condition that may go away by itself in a few months or a couple of years.
Dermatol Pract Concept. 2014. Remission of
generalized erythematous granuloma annulare after improvement of hyperlipidemia
and review of the Japanese literature. Granuloma annulare has been associated
with systemic disease including diabetes mellitus. We report a case of a
62-year-old Japanese woman with generalized erythematous granuloma annulare who
showed remission after substantial improvement in hyperlipidemia following a
strict lipid-lowering diet. The lesion appeared in the lower abdomen one year
before current presentation and subsequently spread to other areas of the trunk
despite treatment with topical steroid and oral epinastine hydrochloride.
Physical examination showed a well-demarcated erythematous plaque measuring 10
cm in diameter with fine scales on the left abdomen, and slightly indurated
pinkish plaques of up to 5 cm in diameter on the right side of the abdomen and
axillae. Clinical laboratory tests showed mild glucose intolerance (HbA1c 6.2%),
mild liver dysfunction (AST: 86 IU/L, ALT: 76 IU/l), slight hypercholesterolemia
(total cholesterol: 235 mg/dl), and severe hyperlipidemia (triglyceride: 962
mg/ml). Histopathological examination of the lesions showed homogenization of
collagen fibers and granulomatous infiltrates between fibers in the upper and
middle dermis. A diagnosis of generalized erythematous granuloma annulare was
established based on the clinical and histopathological findings, especially
with the distribution on more than one anatomic site. A lipid-lowering diet for
three months resulted in major improvement of hyperlipidemia and remission of
the skin lesions. A review of generalized erythematous granuloma annulare in the
Japanese literature indicated a well-known association of granuloma annulare
with diabetes mellitus, however, the relation with hyperlipidemia was described
only recently. This case suggests a possible relationship between GA and
hyperlipidemia, with possible improvement of GA with a lipid-lowering diet.
Granuloma annulare treatment
The primary skin lesion usually is grouped papules in an enlarging annular shape, with color ranging from flesh-colored to erythematous. The two most common types of granuloma annulare are localized, which typically is found on the lateral or dorsal surfaces of the hands and feet; and disseminated, which is widespread. Localized disease generally is self-limited and resolves within one to two years, whereas disseminated disease lasts longer. Because localized granuloma annulare is self-limited, no treatment other than reassurance may be necessary, although liquid nitrogen, injected steroids, or topical steroids under occlusion have been recommended for treatment of localized disease. Established therapies for localized forms of granuloma annulare are glucocorticosteroids, cream PUVA and cryosurgery.
Disseminated granuloma annulare may be treated with one of several systemic therapies such as dapsone, retinoids, niacinamide, antimalarials, psoralen plus ultraviolet A therapy, fumaric acid esters, tacrolimus, and pimecrolimus. Consultation with a dermatologist is recommended because of the possible toxicities of these agents.
Antimalarials, hydroxychloroquine, antileprotics, ultraviolet phototherapy and photochemotherapy, tumour necrosis factor-alpha inhibitor infliximab, fumaric acid esters, oral isotretinoin therapy, topical tacrolimus (calcineurin inhibitor), may be of value in treating granuloma annulare. Some researchers think that hydroxychloroquine should be first-line therapy for generalized granuloma annulare.
Treatment of disseminated granuloma annulare with a 5-lipoxygenase
inhibitor and vitamin E.
Br J Dermatol. 2002.
Histologically, GA is a common non-infectious necrobiotic granulomatous reaction pattern that correlates with a number of different, but relatively specific clinical presentations. The cause or causes of GA are unknown: when localized, it is usually self-limiting, but it may be persistent when disseminated. We present three women who had had disseminated GA for more than 1 year. One patient had previously been treated with isotretinoin with no response. All three patients were treated with vitamin E 400 IU daily and zileuton 2400 mg daily. All responded within 3 months with complete clinical clearing. The anti-inflammatory and immune regulatory effects of vitamin E and zileuton may be an effective treatment in some patients with prolonged disseminated/generalized GA.
An Bras Dermatol. 2017. Granuloma annulare treated with narrowband UVB phototherapy. Treatment may be topical, intralesional or systemic. The use of phototherapy with narrowband UVB is highlighted, whose mechanism of action in this disease is still unclear, probably related to the inhibition of T lymphocytes. A case of a disseminated granuloma annulare of difficult therapeutic management is described. It was treated with narrowband UVB phototherapy twice a week for six months, with good clinical improvement, being a good low-risk therapeutic option and that, in this case, provided quick and satisfactory response.
J Dermatolog Treat. 2018. Methotrexate treatment of generalized granuloma annulare: a retrospective case series.
Subcutaneous granuloma annulare is a benign inflammatory disorder that may be alarming in its presentation because of its rapid growth and extensive differential diagnosis. The majority of cases are children. Most subcutaneous lesions are located on the extremities and some can be seen in the scalp.
Testimonial received on Facebook
I was put on methotrexate for rheumatoid arthritis for a couple months a few years ago and my GA all but disappeared. My RA symptoms did as well. I have had GA for about 7 years now. At one point everywhere but my chest and face. It is now starting to come back all over again and I have also noticed my stiffness coming back. Have you seen any studies done about the correlation between RA and GA and have there been any studies involving autoimmune suppressants and GA?
Ann Dermatol Venereol. 2013. Long-term efficacy of
methotrexate in a patient with generalized granuloma annulare.
Br J Dermatol. 2010. Successful treatment of disseminated granuloma annulare with methotrexate.
I have had granuloma annulare since I was about 8 or 10 years old. My parents brought me to the University of Minnesota. They gave me cortisone injections in my legs. They said I would grow out of it. It was only on my ankles and lower legs. What I remember it went away. During my growing up years I don't remember much about it being disturbing, so it must have been minimal. At about age 35 the granuloma annulare became more noticable. It was very reddish purplish. Everyone was asking if I had bruised my legs. It was still only on my ankles and lower legs. I went to Mayo Clinic at that time. They gave me cortisone cream and the usual options. I have tried to think if there was anything I was doing differently. I had started Zoloft approx. 6 months prior. By this time I had a 6 and 4 year old. I was on Zoloft for about 2 yr. I had it until app. age 45 it went away after I started taking vitamin A & E. At age 47 I started taking Zoloft again and later switched to Lexapro. Since then it has been spreading like crazy. I was still taking vit. A&E. During this time I also started to go through menopause. Just in the last couple weeks I have had spots on my abdomen, upper arms, armpits, elbows. I am getting scared it will go to my face. It is very reddened and prominant. People ask me if I have poison ivy. I don't know what I should do. Do I go back to Mayo and get injections? The other options seem more hazardous to your health. PUVA seems out because I am quite fair skinned. Please can you help me? I don't know what to do or where to go as this disease is spreading very rapidly.
We really don't know much more at this time than the information on this web page.
I take 10mg lexapro tablet once a day and have for the
last4 years? Is there any evidence that this could be causing my granuloma
It is not possible for me to know in any one individual what the cause is, but it is a possibility.
Q. Do the supplements
lipoic acid or
help with granuma annulare? Are there natural supplements, herbs or
vitamins that could be of benefit?
A. There's been no such studies with lipoic or serrapeptase, and I can't think of a mechanism that would make these nutrients be helpful in this condition. As soon as I come across research studies regarding the role of dietary supplements, I will post them on this page.
Q. I have had granuloma anulare for 23 years. Recently I went to a dermatologist who gave me a series of 3 shots of Kenalog. It completely took it away for a period of time. If it ever does spread all over again, i will go back for the Kenalog shots.
Q. I am a 62 year old female who has had
disseminated granuloma annulare for over 3 years. My diagnosis was
initially confirmed by biopsy and again 2 years later by biopsy. I have
been to several dermatologists in the Chicago area and have tried multiple
therapies, topical creams / ointments, antibiotics, other oral
medications, narrowband UVB and PUVA; yet the disease persists. I read
your article, you discuss treatment of disseminated granuloma annulare with
5-lipoxygenase inhibitor and vitamin E, and you also list three drugs:
Zocor, Fosamax and levoxyl at the bottom of your page. Are these drugs
listed as possible therapies, or as possible causative agents? This is
important to me as I take both Fosamax as well as Levoxyl. I have
confidence in my doctor so am only asking you to better understand your
article and to discuss with my physician. The next possible therapy he is
considering is Dapsone.
A. We do not recall why those drugs are listed there, certainly not as a treatment. Perhaps we had a question about someone who was taking these drugs and they ended up on the page while we were cutting and pasting. Sorry we can't be sure, we have thousands of pages and sometimes we lose track of every word or sentence. We wish you well and we will try to keep up with research on this topic.
I was in my late
30's when I first got granuloma anulare on my left ankle. Cortisone cream
cleared it up. It reappeared in the same location about 8-10 years later two
more times. Cortisone cream cleared it up both of those times. About 6 months
ago, it showed up again, but this time numerous spots appeared on my thighs and
torso in addition to the usual location on my ankle. Cortisone cream was slowly
clearing up the spots, but additional spots were rapidly appearing. My doctor
was doing some routine blood work and included a test for vitamin D, at my
request. It turned out that my vitamin D level was only 4.4 when it should have
been in the range of 32 - 100! She told me to take 1000 units of vitamin D
supplements, along with zinc and calcium and advised me to make sure I was
getting plenty of sleep in order to improve my immune system. This cleared up
all of my granuloma anulare spots within a couple of months! Please pass on the
importance testing blood levels of vitamin D. I am now convinced that my immune
system has a direct affect on my granuloma anulare.
Thanks for sharing this. I would need to hear similar reports from a few people to see if there is any merit in this approach.
I am a 54 year old female with granuloma annulare. I do take thyroid pills daily 1.75 mg. For the last three years I haven't been able to cure this problem. It is all over my body. My depression is getting worst, I can't stand to look at my self any more. What is it I can do to get rid of this problem? What supplements can I take? I have seen close to 8 doctor's in three years, no one has cure it yet. I would deeply appreciate some advice on what to do.
I have been suffering with generalized granuloma
annulare for 9 years. I have seen numerous doctors and have gotten no other
treatment indications other than steroids and ultraviolet with little or no
apparent effect. I was told to take 400 IU of vitamin E daily along with a daily
dose of Zileuton and dietary modifications. My condition is still spreading even
with the Zileuton and is quite unsightly. I am an otherwise healthy 60 year old
women who exercises regularly and is in good physical condition. I would be so
grateful for any treatment approach, including the one I mentioned above. Please
I have been searching the medical literature for natural ways to treat this condition but still have not found good studies that indicate an effective approach.
I have had CFIDS for 10 years and 2 years ago I
developed granuloma annulare on my arms. My dermatologist was clueless but gave
me cortisol creams. I never used is as my naturopathic doctor (ND) tested me and
discovered I had protozoa contamination. He told me to get rid of my cat. I told
him Iíd rather shoot him. So he modified his recommendation to not kiss my cat.
I could follow that. He is treating me with Lypo-Spheric Vitamin C (4,000-6,000
IU), Premier Research Labs Quantum Noni 4 tablets a day, and one other product
that I can not remember, maybe d-mannose at 2 teaspoons a day. Anyway after 7
months the parasite level in my urine dropped from 85% down to 15% this last
month. He used parasite test drops in a measured urine test tube. I assume that
within another 2 months, the lesions will disappear completely and the urine
will be totally clear. I am in a support group and after sharing my information,
I discovered that 4 of us have granuloma annulare. They are now being treated by
my ND, as the dermatologists they have seen donít have a clue.
It's difficult to say whether the natural supplements and vitamins made a difference in your particular case or whether it was a matter of time.
I'm 60 years young and have started developing the
condition within the last year. I visited my dermatologist and that is what the
biopsy revealed. I've had a complete physical and blood work. All is well and
I'm in excellent shape, running daily and eating a, mostly, vegetarian diet. I
do take lots of supplements. This is what I take: Raw Foods Multi for men over
50, Ubiquinol CoQ10,Gamma Vitamin E, Vitamin D3, Glucosamine, Chondrotin, MSM,
Policosanol, Kyolic Garlic, Lutein, Milk Thistle, Choleralla, Prostate Formula,
Digest Gold Primal Defense, Carlson Fish Oil, Nattokinase, Host Defense (16
mushrooms), Immune Modulator Infopeptide Spray (balances cytokine production to
enhance immune function). My question is can supplements, possibly, be a cause
of Granuloma Annulare? I'm thinking, maybe, the immune boosting supplements like
Host Defense and Immune Modulator can be causing my immune system to overreact
causing this reaction. Is that, even remotely, a possibility, in your opinion?
Since there is still a lot to be learned about this condition and what causes it, it is theoretically possible that natural vitamins, herbs, and dietary supplements could be a cause in some individuals.
I had this condition for 7 years. It may have resulted from chemotherapy for breast cancer. It was diagnosed by two doctors and a biopsy. A friend suggested I try MSM. After taking oral doses of 1200 units per day for about 2 weeks, the condition cleared by about 80%. Within 2 months it had completely cleared. After several years I stopped taking daily doses of MSM and the condition began to return after a few months, so I began using MSM again, and the condition cleared up again. I continue to use the MSM.
Just wanted to add my experience with treating GA. It showed up on one hand about 2 years ago, and has spread to the second hand. Long story short, I don't like taking drugs. I've read about Vitamin E, Emu oil, and/or Tea Tree oil (applied topically) working for some folks, and one person decided to combine all 3 to apply topically. That's what I've been doing for 2 months, and I see a definite improvement! No new spots either! I DO notice that I have to apply it regularly, at least 2 times a day, for the reduction to continue, and 3-4 times a day is even better. The Emu oil alone seems to work, too. I am also taking 5000 mg Vitamin D, plus other vitamins, and glucosamine. I plan to add MSM to the mix, just to see if that helps. Thanks for continuing to post information on this baffling condition! I hope that we will eventually figure out what the heck this is, and how to treat it!
I am 58 and had generalized GA for six years, which was resistant to most treatments, though some slowing was noted with the steroid salve. That said, I had it all over my body except face and back. Nine months ago, I was diagnosed with hypothyroidism and prescribed synthetic thyroxin. Within two months, the GA had faded about 50%; within six months, 90% of the GA has faded and remains gone. I have slight remnants, mostly outlines from the largest sites. Since thyroiditis has been mentioned for years as a possible cause of GA, my dermatologist is now going to order thyroid tests for his GA patients. I'm sending this to you since you are receiving correspondence from other post-menopausal who have been suffering from this medical condition for years.
I have recently been diagnosed with granuloma annulare
and it spread all over). Sometimes linked to diabetes and thyroid, I checked and
donít have either. The unsightly patches of raised, bumpy, ring-shaped lesions
(rash) are causing me emotional distress so I am desperately seeking ways to
make the rash disappear and find what causes this disorder (food, toxins, etc.)
to eliminate what may be going on internally. Since a reaction in the immune
system may play a role, I am seeking insight as to what may have triggered this
and how to eliminate it completely. I am on a mission to find out what may have
caused this, what I can do to make it go away and never come back. I have read
your website and feel you are one of the only Doctors with a real concern for
the patients who experience this disease and take the time to answer their
questions and aid in their quest to find a cure. I would like to know if any of
your patients tried a gluten free and/or low glycemic diet? I am considering
trying both. After eating large quantities of fruit especially mango, I may have
spiked my sugar levels. I am also allergic to latex and have a history of
chronic idiopathic urticaria totally under control with Fexfenodine. I also do a
lot of yard work and may have gotten bitten by a spider or the pesticides in the
yard may have taken its toll on my system.
It is worth trying different treatment plans, including gluten free diets. There are many causes for this condition and it is difficult to diagnose and treat. Hopefully many cases resolve with time.
Ive had granuloma annulare for 38 years. I've had 4 pregnancies where each time it has disappeared each time. Also whenever I'm on birth control, it goes away. After studying this and talking to a lot of people who have GA, they have found it disappears with pregnancy too.
I am 65 years of age and am suffering from Granuloma Annulare, I have had it for the past 2 years after taking simvastatin. I developed a certain rash (on the patient check form in the prescription package) took 4-5 tablets and developed the exact rash they said may happen, following that I developed GA. I also have thyroidism, which was diagnosed a couple of years ago as well. My GA has not responded to Ultra Violet Light Treatment and also coritsone creams, which were recommended by my dermotologist. I have always followed a healthy lifestyle regarding food intake.
I was researching this skin condition and came across your question-answer page. About 2 months ago I was diagnosed with this. Iím wondering if you have any new information about natural or other cures for this? The dermatologist gave me an Rx for a steroid cream, but I donít think it is helping much. The older rashes appear to be getting better, but Iím noticing some new spots. They are all on my legs and ankles. I do take Zocor. This is such a weird looking rash it drives me crazy!
My 16 year old daughter was diagnosed with GA and was
given Temovate ointment, but she also takes 5mg of Tapazole for her overactive
thyroid. I was wondering if a multi-vitamin would help or not?
It is not possible for me to predict in any one individual the influence of supplementing with a multivitamin or other product. Most likely it would not have much of an influence.
I have had this condition for over 10 years. I have tried
everything to get rid of it. It may be caused by the chemo drugs I took for
breast cancer. I am considering ROM therapy. Have you heard of it? Monthly
combination therapy of rifampicin 600 mg, ofloxacin 400 mg, and minocycline 100
mg (ROM) is used for treating leprosy which shares both clinical and
histopathologic similarities with GA.
A. I am not very familiar with ROM therapy.
I am a 35 year old female. I do have a thyroid issue which is very hard to control. It has been one year that I have been diagnosed with granuloma annulare. Itís on my feet and hands. Iíve gotten cortisone injections and it has not helped at all. The ones on my hands are only under the skin bumps and not red. But my feet are red. Iím so scared and concerned.