Generalized granuloma annulare (GGA) is an uncommon variant of granuloma annulare (GA), representing 8% to 15% of all cases of GA. It is defined as affecting at least the trunk and either the upper, lower, or both, extremities . GGA most frequently occurs in middle-aged to elderly adults, between 30 and 60 years old. However, in 20% of the cases it occurs before the age of 10 years and rare cases of GGA in infants have been reported. The clinical morphologic patterns of GGA can be divided into the annular and non-annular patterns. Among them, the non-annular pattern is composed of symmetrically scattered papules often coalescing papules. It is different from the annular pattern by a nearly equal female-to-male ratio, certain laboratory abnormalities such as a lower incidence of elevated serum lipids and a more frequent occurrence of increased titers of gamma globulins and immunoglobulins. The non-annular pattern also shows positive staining for lipid more frequently. In our two cases, erythematous papules were diffusely scattered on the trunk, upper and lower extremities and they are compatible with non-annular GGA.
Typical histopathologic findings of GGA are ne- crobiotic collagen and mucin in the dermis with surrounding inflammatory cells of histiocytes, multinucleated giant cells, and a few acute inflammatory cells. Although histopathologic differences between localized GA and GGA are minimal, collagen sclerosis, palisading pattern and decreased or absent elastic fiber in granulomatous inflammation foci occurred more commonly in localized GA than in GGA . In our two cases, collagen sclerosis and palisading pattern are not prominent on the histopathology.
GGA is a chronic disease with a relapsing course and shows a poor therapeutic response. These circumstances have led to numerous treatments, including systemic corticosteroid, isotretinoin, PUVA, potassium iodide, sulfone, hydroxychloroquine, niacinamide, topical vitamin E, topical corticosteroid, and cryotherapy. However, in our two cases, the lesions disappeared leaving hyperpig- mentation after treatment with topical or systemic corticosteroid for a month. No recurrence was observed during the follow up period of 15 months and 4 months, respectively.
A 68-day-old infant with generalized perforating GA was the youngest patient with GGA. However, to the best of our knowledge, these two cases of GGA are the earliest onset of non-perforating GGA reported in the English literature.