Management of Periocular Granuloma Annulare Using Topical Dapsone

Granuloma annulare is a disease characterized by granulomatous inflammation of the dermis. Localized granuloma annulare may resolve spontaneously, while generalized granuloma annulare may persist for decades. The authors present the case of a 41-year-old Hispanic man with a two-week history of periocular granuloma annulare. Due to previously reported success in the use of systemic dapsone for the treatment of granuloma annulare, and the periocular proximity of the patient’s lesion, topical dapsone was used for treatment. Various additional therapies for the management of granuloma annulare have been reported, such as topical and systemic steroids, isotretinoin, pentoxifylline, cyclosporine, Interferon gamma, potassium iodide, nicotinamide, niacinamide, salicylic acid, fumaric acid ester, etanercept, infliximab, and hydroxychloroquine. Additional clinical trials are necessary to further evaluate the effectiveness of topical dapsone in the management of granuloma annulare.Granuloma annulare (GA) was first identified in 1985 by Fox1 and has since been well-described in the literature as benign, firm, skin-colored, and solitary or grouped papules or nodules arranged in an annular pattern.2 When the nodules increase in size the annular ring arrangement can become obscured.3 GA most commonly occurs in women in the first three decades of life.2 The estimated distribution of GA lesions per the literature is 60 percent on the hands or arms, 20 percent on the feet and legs, seven percent involving both upper and lower extremities, five percent on the trunk, and five percent involving any other areas, such as the face and scalp.4 It is rare to see GA on the face and scalp especially in adults as it usually occurs in children.3 There have however been some instances of GA occurring on the face in adults as reported by Coskey in 1979 who studied the literature and found 44 reported cases of facial GA of which 25 were adults.5 There are four subtypes of GA: localized, perforating, subcutaneous, and generalized.3 The most common subtype is localized GA, which occurs in children and presents clinically as small, firm, asymptomatic, skin-colored or red papules or nodules in an arciform pattern and is histologically consistent with no epidermal change. This type runs the course of enlargement and later regression.3 The second type is the perforating type, which appears as umbilicated lesions. The third type is subcutaneous GA, which appears clinically as subcutaneous nodules either mobile or fixed to the periosteum or bone located most commonly on the extremities.3 The fourth type is generalized/disseminated GA, which occurs primarily in adults and presents as widespread flesh-colored to violaceous papules or plaques. Although there is some controversy over this relationship, generalized GA has been accepted to be significantly associated with diabetes mellitus.3