Talk:Necrobiotic granulomatous processes

Granuloma annulare

It is a frequent benign chronic skin disease characterized histologically by the formation of necrobiotic granulomas, typical clinical manifestations are ring-shaped (annular) papules. The disease mainly affects children and young adults, more often women.

Etiology

Unknown, in 20% it is associated with diabetes mellitus.

Clinical picture

• Localized form - a hard reddish nodule, increases in the periphery with a palpable mass of closely grouped sharply demarcated papules; the center sinks in - the skin here has a normal appearance - the manifestation acquires an annular arrangement with a diameter of several centimeters without subjective symptoms; most often above the joints - mainly the backs of the hands, feet, on the fingers, around the ankles and elbows.
• Rare forms - disseminated, erythematous, subcutaneous, perforating.

Diagnosis

Clinical appearance + histological evidence of necrobiotic granuloma; in the case of the disseminated form, diabetes mellitus must be ruled out.

Differential diagnosis

Localized form – tinea, lichen planus annular form, sarcoidosis, lupus erythematodes.

Therapy

Localized form – locally corticoids; systemic treatment is usually not necessary.

Progress

Mostly spontaneous healing ad integrum within 1-2 years.

Necrobiosis lipoidica (diabeticorum)

A chronic disease with the formation of necrobiotic granulomas, most often affecting the lower legs; about 1% of diabetics - up to 50% of patients with this disease have DM; most often middle-aged women.

Etiology

Unknown, signs of small vessel damage may be related to diabetic microangiopathy; sometimes changes in the character of vasculitis.

Clinical picture

Front sides of lower legs; sharply demarcated, mostly bilateral, indurated, smooth, shiny deposits to surfaces of various shapes, reddish-brown at the edges; the center is rather orange or yellowish with visible vascular ectasias; about 30% develop poorly healing ulcers.

Diagnosis

Clinical appearance and typical localization, biopsy may lead to the formation of an ulcer.

Differential diagnosis

Mainly granuloma annulare, other ulcers.

Therapy

Mostly unsuccessful, local corticoids are tried in occlusion or intralesionally; microcirculation treatment – venotonics and rheology – sometimes leads to improvement.

Progress

Chronic, in 20% improvement and fading of bearings.

Rheumatism nodosus

Subcutaneous nodules affecting 20% of people with rheumatoid arthritis; histologically necrobiotic granulomas.

Etiology

Most likely vascular changes and traumatization.

Clinical picture

Multiple, subcutaneous, painful to touch nodules – typically over the elbows, knees, ulnar sides of the forearms and over the joints of the hands; nodes are rigid and movable.

Diagnosis

Clinical picture + histology – necrobiosis = more extensive areas of degeneration of the coria collagen ligament, surrounded by histiocytes and giant cells.

Differential diagnosis

Subcutaneous granuloma annulare is often difficult to differentiate, gouty nodules, mesenchymal tumors, acrodermatitis chronica atrophicans.

Therapy

In most cases, intralesional application of corticoids is not necessary, if they are painful and limit movement, then surgical excision.

Progress

Rheumatic nodules are permanent, causing difficulties in normal use of the hand.

Links

References

Jiří Štork et al. Dermatovenerology. Galen, Carolinum. 2008;

Presentation on the website http://kozni.lf1.cuni.cz;

Lectures by teachers at the Dermatovenerology Clinic of the 1st Faculty of Medicine, UK and VFN;

Jakub Holešovský, questions from dermatovenerology