The Patient Who Didn’t Complain Enough?

A 70-year-old woman presents to dermatology with asymptomatic lesions on her legs that, she reports, have been there for decades but are now becoming larger and more unsightly. She’s tried several courses of antifungal creams and pills with no success.

In all this time, she hasn’t seen a dermatology provider, because “no one ever felt the need” to refer her since her diagnosis was so “obvious.” When the changes began, however, her children finally convinced her to consult a specialist.

Her medical history is otherwise unremarkable, with no problems directly related to her skin issues. She denies both personal and family history of diabetes.

EXAMINATION
There are numerous impressive, reddish brown, annular plaques with slightly raised borders and clearing centers on the patient’s legs. There are also a few on her arms and one or two on her trunk. There is no epidermal component (scale or other surface disruption) on any of the lesions, which range in size from 2 cm to 15 cm.

What is the diagnosis?

DISCUSSION
It’s hard to believe that any patient could go this long with such a florid condition and never be seen by dermatology. Patients have an obligation to speak up—to complain, as it were—but some are too compliant. This woman’s primary care providers should have attached some significance to the nonresponse to treatment, one explanation for which might have been erroneous diagnosis.

Everybody knows that big round things are fungal, except when they aren’t. That’s where dermatology providers shine. Our training is all about development of differentials, as in: What are the various potential explanations for big round lesions? What would those things look like, and how could we distinguish them from fungal infection?

Here’s one huge clue: Fungal infection commonly refers to a relatively trivial, superficial infection of the outermost layer of the skin, the stratum corneum. By its very nature, it almost always involves scaling; if those scales are examined microscopically, the fungal elements can be seen, thus confirming the diagnosis.

When there is no scale, and the condition fails to respond to antifungal medications, alternative diagnoses must be considered. One major item that fits the bill is granuloma annulare (GA), an asymptomatic condition that presents with reddish brown, distinctly annular papules and plaques with raised (papular) borders and cleared centers. Though GA is extremely common, it is almost always misdiagnosed initially as fungal infection.

Besides the lack of scaling, GA lesions have some other characteristics that aid diagnosis. They’re commonly seen on extremities, especially the dorsa of feet and hands, and are far more common on women (especially young ones) than on men.

Although usually reddish brown, the lesions will be darker on patients with darker skin. It should be mentioned that this patient’s lesions were unusually large and extensive. Most cases are far more modest in size and distribution.

When necessary, punch biopsy shows what is called a palisaded granuloma. This, taken in context with the clinical picture, nails down the diagnosis.

One other piece of information is good to know: GA is quite common. You will see it, regularly.

Since the cause of GA is unknown, treatment can be problematic. Fortunately, the problem almost always resolves, with or without treatment. A few of this patient’s lesions were treated (for cosmetic reasons) with intralesional steroid injection.

TAKE-HOME LEARNING POINTS
• Granuloma annulare (GA) is a benign asymptomatic condition that presents with annular, reddish brown intradermal lesions.

• GA is commonly seen on the dorsa of feet, hands, and arms, especially of young women.

• GA lesions are intradermal, not epidermal, so there is no scaling or other disturbance of the skin surface.

• GA treatment is problematic, but the problem usually resolves on its own. 

A 70-year-old woman presents to dermatology with asymptomatic lesions on her legs that, she reports, have been there for decades but are now becoming larger and more unsightly. She’s tried several courses of antifungal creams and pills with no success.

In all this time, she hasn’t seen a dermatology provider, because “no one ever felt the need” to refer her since her diagnosis was so “obvious.” When the changes began, however, her children finally convinced her to consult a specialist.

Her medical history is otherwise unremarkable, with no problems directly related to her skin issues. She denies both personal and family history of diabetes.

EXAMINATION
There are numerous impressive, reddish brown, annular plaques with slightly raised borders and clearing centers on the patient’s legs. There are also a few on her arms and one or two on her trunk. There is no epidermal component (scale or other surface disruption) on any of the lesions, which range in size from 2 cm to 15 cm.

What is the diagnosis?

DISCUSSION
It’s hard to believe that any patient could go this long with such a florid condition and never be seen by dermatology. Patients have an obligation to speak up—to complain, as it were—but some are too compliant. This woman’s primary care providers should have attached some significance to the nonresponse to treatment, one explanation for which might have been erroneous diagnosis.

Everybody knows that big round things are fungal, except when they aren’t. That’s where dermatology providers shine. Our training is all about development of differentials, as in: What are the various potential explanations for big round lesions? What would those things look like, and how could we distinguish them from fungal infection?

Here’s one huge clue: Fungal infection commonly refers to a relatively trivial, superficial infection of the outermost layer of the skin, the stratum corneum. By its very nature, it almost always involves scaling; if those scales are examined microscopically, the fungal elements can be seen, thus confirming the diagnosis.

When there is no scale, and the condition fails to respond to antifungal medications, alternative diagnoses must be considered. One major item that fits the bill is granuloma annulare (GA), an asymptomatic condition that presents with reddish brown, distinctly annular papules and plaques with raised (papular) borders and cleared centers. Though GA is extremely common, it is almost always misdiagnosed initially as fungal infection.

Besides the lack of scaling, GA lesions have some other characteristics that aid diagnosis. They’re commonly seen on extremities, especially the dorsa of feet and hands, and are far more common on women (especially young ones) than on men.

Although usually reddish brown, the lesions will be darker on patients with darker skin. It should be mentioned that this patient’s lesions were unusually large and extensive. Most cases are far more modest in size and distribution.

When necessary, punch biopsy shows what is called a palisaded granuloma. This, taken in context with the clinical picture, nails down the diagnosis.

One other piece of information is good to know: GA is quite common. You will see it, regularly.

Since the cause of GA is unknown, treatment can be problematic. Fortunately, the problem almost always resolves, with or without treatment. A few of this patient’s lesions were treated (for cosmetic reasons) with intralesional steroid injection.

TAKE-HOME LEARNING POINTS
• Granuloma annulare (GA) is a benign asymptomatic condition that presents with annular, reddish brown intradermal lesions.

• GA is commonly seen on the dorsa of feet, hands, and arms, especially of young women.

• GA lesions are intradermal, not epidermal, so there is no scaling or other disturbance of the skin surface.

• GA treatment is problematic, but the problem usually resolves on its own. 

A 70-year-old woman presents to dermatology with asymptomatic lesions on her legs that, she reports, have been there for decades but are now becoming larger and more unsightly. She’s tried several courses of antifungal creams and pills with no success.

In all this time, she hasn’t seen a dermatology provider, because “no one ever felt the need” to refer her since her diagnosis was so “obvious.” When the changes began, however, her children finally convinced her to consult a specialist.

Her medical history is otherwise unremarkable, with no problems directly related to her skin issues. She denies both personal and family history of diabetes.

EXAMINATION
There are numerous impressive, reddish brown, annular plaques with slightly raised borders and clearing centers on the patient’s legs. There are also a few on her arms and one or two on her trunk. There is no epidermal component (scale or other surface disruption) on any of the lesions, which range in size from 2 cm to 15 cm.

What is the diagnosis?

DISCUSSION
It’s hard to believe that any patient could go this long with such a florid condition and never be seen by dermatology. Patients have an obligation to speak up—to complain, as it were—but some are too compliant. This woman’s primary care providers should have attached some significance to the nonresponse to treatment, one explanation for which might have been erroneous diagnosis.

Everybody knows that big round things are fungal, except when they aren’t. That’s where dermatology providers shine. Our training is all about development of differentials, as in: What are the various potential explanations for big round lesions? What would those things look like, and how could we distinguish them from fungal infection?

Here’s one huge clue: Fungal infection commonly refers to a relatively trivial, superficial infection of the outermost layer of the skin, the stratum corneum. By its very nature, it almost always involves scaling; if those scales are examined microscopically, the fungal elements can be seen, thus confirming the diagnosis.

When there is no scale, and the condition fails to respond to antifungal medications, alternative diagnoses must be considered. One major item that fits the bill is granuloma annulare (GA), an asymptomatic condition that presents with reddish brown, distinctly annular papules and plaques with raised (papular) borders and cleared centers. Though GA is extremely common, it is almost always misdiagnosed initially as fungal infection.

Besides the lack of scaling, GA lesions have some other characteristics that aid diagnosis. They’re commonly seen on extremities, especially the dorsa of feet and hands, and are far more common on women (especially young ones) than on men.

Although usually reddish brown, the lesions will be darker on patients with darker skin. It should be mentioned that this patient’s lesions were unusually large and extensive. Most cases are far more modest in size and distribution.

When necessary, punch biopsy shows what is called a palisaded granuloma. This, taken in context with the clinical picture, nails down the diagnosis.

One other piece of information is good to know: GA is quite common. You will see it, regularly.

Since the cause of GA is unknown, treatment can be problematic. Fortunately, the problem almost always resolves, with or without treatment. A few of this patient’s lesions were treated (for cosmetic reasons) with intralesional steroid injection.

TAKE-HOME LEARNING POINTS
• Granuloma annulare (GA) is a benign asymptomatic condition that presents with annular, reddish brown intradermal lesions.

• GA is commonly seen on the dorsa of feet, hands, and arms, especially of young women.

• GA lesions are intradermal, not epidermal, so there is no scaling or other disturbance of the skin surface.

• GA treatment is problematic, but the problem usually resolves on its own.