- A 7 year old female presented with a skin biopsy from her left gluteal region for a clinical diagnosis of granuloma annulare. - Microscopic examination showed features consistent with granuloma annulare including hyperkeratosis, acanthosis, lymphocytic infiltration, and histiocytes surrounding degenerated collagen extending into the dermis. - Granuloma annulare is a benign inflammatory dermatosis more common in females that involves skin and subcutaneous tissue, though the etiology is unknown.

1. PATIENT DETAILS
• Age: 7 years/ Female
• Hospital OP/ IP No: 17/387894
• Biopsy No: 3150/17
• Date Of Receiving Specimen : 29/11/2017
• Clinical Diagnosis : Granuloma annulare.
• Nature of specimen: Skin biopsy from left
gluteal region.
.

2. GROSS EXAMINATION
Received single skin punch biopsy measuring 0.5x0.5x0.3cm.
All embedded.

3. MICROSCOPIC EXAMINATION

4. MICROSCOPIC EXAMINATION

5. MICROSCOPIC EXAMINATION

6. MICROSCOPIC EXAMINATION
Sections studied shows
• epidermis with hyperkeratosis, focal acanthosis,
elongation of rete pegs and follicular keratotic plugging.
• the papillary dermis shows dense perivascular and
periadnexal lymphocytic infiltration along with focal
collection of histiocytes and macrophages seen around
degenerated collagen.
• the inflammation is extending upto reticular dermis and
subcutaneous plane.

7. IMPRESSION
• Features consistent with granuloma annulare
– left gluteal region.

8. DISCUSSION

9. Granuloma annulare
• A benign inflammatory, self-limiting granulomatous
dermatoses that is seen in both adults and children
• Females are more commonly affected than males.
• The lesions involves skin and/or subcutaneous tissue.

10. Granuloma annulare
• The etiology of granuloma annulare is unknown.
• Lesions could be related to insect bites, sun exposure, viral
infections, diabetes, thyroiditis, immunoglobulin-mediated
vasculitis, and certain medications such as antibiotics,
antiinflammatory agents and oral contraceptives.
• Cases have also been reported in patients with AIDS,
sarcoidosis, hepatitis C infection, Hodgkin's and non Hodgkin's
lymphoma, metastatic adenocarcinoma and granulomatous
mycosis fungoides.

11. Histopathology
Histological patterns in Granuloma Annulare:
1. Necrobiotic granuloma.
2. Interstitial or 'incomplete' form - Most common.
3. Granuloma of sarcoidal or tuberculoid type with epithelioid
histiocytes or a type of giant cell - Rare

12. Differential Diagnosis
• Necrobiosis lipodica
• Annular elastolytic giant cell granuloma
• Rheumatoid arthritis and rheumatic fever
nodules.

13. Differential Diagnosis

14. Annular elastolytic giant cell granuloma

15. Necrobiosis Lipoidica
• Predominantly involves the dermis.
• Abundant mucin is distinctly
uncommon.
• Multilayered necrobiosis (stacks of
plates) with open ends.
• Thickened collagen bundles within
palisaded granuloma.
• Shows extensive deposits of lipids or
nodular lymphocytic infiltrates in
the deep dermis or subcutis.
• Numerous deep dermal plasma
cells.

16. Rheumatoid Nodule
• Sharp irregular areas of necrobiosis (huge
deposits of fibrin).
• Located in the subcutis and deep reticular
dermis.
• Surrounded by a palisade of elongated
histiocytes.
• Stroma surrounding the nodules show
perivascular lymphocytic infiltrate
including plasma cells.
• Some neutrophils and nuclear dusts of
neutrophils may be present.
• Acute or chronic thrombotic endoarteritis
is observed in some cases around
rheumatoid nodules.
• Old lesions show dense fibrosis, clefts and
cystic degeneration.

17. Special Stains
• Mucin stains such as colloidal iron and alcian blue may be
used to highlight the increased connective tissue mucins.
• Histiocytes gives positivity to vimentin and CD68.

18. References
Lever's histopathology of the skin. 10th ed.

19. Thank you