Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Case Letter
88 (
6
); 800-803
doi:
10.25259/IJDVL_197_2021
pmid:
36331829

Auricular granuloma annulare

Department of Dermatovenereology, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
Department of Pathology, Chengdu Second People’s Hospital, Chengdu, Sichuan, China

Corresponding author: Dr. Tao Chen, Department of Dermatovenereology, Chengdu Second People’s Hospital, Chengdu, Sichuan, China. 13980427003@163.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Zhang L, Jiang C, Wang W, He L, Chen T. Auricular granuloma annulare. Indian J Dermatol Venereol Leprol 2022;88:800-3.

Sir,

Granuloma annulare, first described by Colcott and Fox in 1895, and formally named in 1902 by Radcliffe-Crocker, is a common noninfectious granulomatous cutaneous condition.1 Granuloma annulare has several sub-types, including localised, generalised, sub-cutaneous, macular or patch and various atypical morphologies. Granuloma annulare localised to the external ear is very rare. Herein, we report a case of auricular granuloma annulare with dermoscopic manifestations.

A 49-year-old male presented with a 6-month history of multiple asymptomatic firm skin-coloured to erythematous papules involving both auricular antihelixes [Figures 1a and b]. There was no history of trauma, insect bite, or excess solar exposure. The patient was in good health and stated no prior medical history. On dermoscopy (JD801D, Jiangsu Jieda Technology Co., Ltd, Jiangsu, China), the right auricular lesion presented a daisy pattern comprising a central yellow crust with peripheral linear and hairpin vessels on a white background [Figure 2a]; and the left auricular lesion revealed a central yellowish-orange structure-less area with surrounding capillary network [Figure 2b]. A lesional skin biopsy and histopathological examination from the right ear revealed palisading infiltration of histiocytes and lymphocytes around degenerated collagen fibres in the dermis [Figure 3], suggestive of granuloma annulare. After three months of topical 0.05% halobetasole cream, the lesions resolved without any recurrence at 1-year follow-up.

Multiple firm skin-colored papules (arrows) on the bilateral antihelixes: (a) right, (b) left
Figure 1a and b:
Multiple firm skin-colored papules (arrows) on the bilateral antihelixes: (a) right, (b) left
(a) The right lesion showed central yellow crust (pentagram) and peripheral linear (yellow arrows) and hairpin vessels (black arrows) on a white background. (non-contact polarised dermoscopy, ×50); (b) the left lesion showed central yellowish-orange structureless area (triangle) with the peripheral capillary network (blue arrows). (non-contact polarised dermoscopy, ×50)
Figure 2a and b:
(a) The right lesion showed central yellow crust (pentagram) and peripheral linear (yellow arrows) and hairpin vessels (black arrows) on a white background. (non-contact polarised dermoscopy, ×50); (b) the left lesion showed central yellowish-orange structureless area (triangle) with the peripheral capillary network (blue arrows). (non-contact polarised dermoscopy, ×50)
Dermal palisading infiltration contained histiocytes and lymphocytes around degenerated collagen fibres (H&E, ×200)
Figure 3:
Dermal palisading infiltration contained histiocytes and lymphocytes around degenerated collagen fibres (H&E, ×200)

Granuloma annulare is a common non-infectious granulomatous cutaneous condition classically presenting as annular grouped skin-coloured to erythematous papules on the extremities. Although the exact pathogenesis remains unclear, cell-mediated hypersensitivity reaction is one of the proposed explanations for its development.2 It may occur as an isolated idiopathic entity, however, some reports have associated it with diabetes, hyperlipidemia, malignancy, thyroid disease and systemic infections.2 Several triggers of granuloma annulare have been reported, such as lightning strikes, tattoos, insect bites, contact dermatitis, vaccination, isomorphic response and medication.2

Granuloma annulare is more prevalent in females, with a female-to-male ratio of 2:1, and onset commonly occurs before 30 years age.3 It has varying morphologies and sub-types, and the common subtypes include localised, generalised, perforating and sub-cutaneous granuloma annulare. Other rare subtypes are linear, palmar, patch, pustular and giant granuloma annulare. Histopathology is a confirmatory diagnostic tool, characterised by dermal collagen degeneration, mucin deposition and either a palisaded or interstitial histiocytic infiltrate. The common dermoscopic features of granuloma annulare include multiform whitish areas, yellowish-orange structureless areas, and unfocused vessels (dotted, linear and branching) with an evident pinkish-reddish background.4,5 Whitish areas probably result from collagen degeneration and mucin deposition in dermis, while the granuomatous infiltrate is depicted by yellowish-orange structureless areas.4 Other dermoscopic features include pigmented structures, whitish scaling, rosettes, and crystalline leaf venations.4,5 Apart from the common dermoscopic features of granuloma annulare, we observed a special daisy pattern in our patient, which has also been described in chondrodermatitis nodularis helicis.6

Granuloma annulare localised to the external ear is very rare. To date, a total of 12 cases of auricular granuloma annulare have been reported in the literature.7,16 While granuloma annulare has female predilection, all patients with auricular granuloma annulare were male. Table 1 summarizes the cases of auricular granuloma annulare reported in literature [Table 1]. Although the exact reason for granuloma annulare on the external ear is unknown, trauma seems to be related, as reported in five patients. The lesions of auricular granuloma annulare commonly involve bilateral helixes or/and antihelixes, or occasionally ear lobe, and present as multiple skin-coloured, yellow, or erythematous papules and nodules. The majority of auricular granuloma annulare are asymptomatic, while occasional slight tenderness may be present. The histopathologic features are consistent with typical granuloma annulare. Farrar reported a case of auricular granuloma annulare with perforating features, and the lesions presented on extra-auricular sites.12 In 10 patients, the lesions were localised to the ear [Table 1]. Auricular granuloma annulare usually resolves with treatment, and only one patient presented with local recurrence in the literature.15 The effective management options include trauma avoidance, topical glucocorticoids or calcineurin inhibitors, cryotherapy and excision.7,8

Table 1: The clinical features of 11 cases auricular granuloma annulare
Case Sex Age, year Course Clinical features Sites Possible inducement Treatment Prognosis Author
1 M 36 Several months Single tender nodule Left ear lobe Trauma Excision No recurrence Mills, 1992
2 M 21 6 months Multiple nodules Both helixes and antihelixes Trauma Excision Not described Mills, 1992
3 M 27 3 years Yellow papules Both inner helixes None Cryotherapy Improved Farrar, 2002
4 M 40 5–6 years Multiple nodules Left antihelix Trauma Not described Not described Raghava, 2004
5 M 28 1 year Skin-coloured papules Both antihelixes None Topical steroid And pimecrolimus Improved Kim, 2009
6 M 26 5 years Yellow papules Both antihelixes None Cryotherapy, excision No recurrence Dias, 2010
7 M 31 18 months Skin-coloured papules Right antihelix Trauma Avoid trauma Spontaneous regression without recurrence Shim, 2010
8 M 36 1 month Skin-coloured papules Both antihelixes Trauma Local injection of steroid No recurrence Shim, 2010
9 M 20 10 years Yellowish tender papules Left antihelix None Excision, topical steroid Recurrence Gerdes, 2013
10 M 7 6 months Skin-coloured papules Both helixes and antihelixes None Topical steroid Improved Cho, 2014
11 M 49 6 months Skin-coloured, reddish papules Both antihelixes None Topical steroid No recurrence Our case

The differential diagnoses of granuloma annulare include rheumatoid nodules, chondrodermatitis nodularis helicis, auricular pseudocyst, sarcoidosis and epidermal cysts. Rheumatoid nodules are well-demarcated, flesh-coloured, sub-cutaneous lumps or masses, usually encountered on extensor surfaces, pressure and trauma-prone areas, in patients with rheumatoid arthritis. Typical histologic features include necrobiosis, with fibrin deposition and palisading epithelioid histiocytes.17 The dermoscopic findings comprise a pink or pink and white mixed homogeneous background, reticulate pigmentation, and fewer vessels.5 Chondrodermatitis nodularis helicis typically presents as a tender round nodule with raised edges with a central ulcer or crust, involving the helix or antihelix. Histopathology reveals epidermal ulceration with surrounding acanthosis, orthokeratosis, dermal inflammation and hyalinised eosinophilic material overlying the cartilage.18 The dermoscopic feature of chondrodermatitis nodularis helicis is a daisy pattern consisting of thick white lines, radially arranged, converging to a central rounded yellow/brown clod.6 Auricular pseudocyst is a rare benign condition corresponding to an intra-cartilaginous collection resulting in a non-inflammatory cystic swelling of the ear. Ultrasound is a useful early diagnostic tool for auricular pseudocyst.19 About 25% of sarcoidosis patients have cutaneous lesions, manifesting as maculopapules, nodules, plaques, sub-cutaneous nodules, infiltrative scars and lupus pernio.20 Histologic examination of sarcoidosis shows well-demarcated islands of epithelioid cells with occasional giant cell formation and no necrosis.20 Dermoscopy of sarcoidosis displays translucent, orange or yellowish-orange structureless areas which may be focal or diffuse along with well-focused vessels of different morphologies.5

In conclusion, we have reported a rare case of auricular granuloma annulare. Dermoscopy is a useful, non-invasive adjunctive diagnostic tool for auricular granuloma annulare, while histopathology is confirmatory. The dermoscopic findings include a daisy pattern, yellowish-orange structureless area and unfocused multiform vessels.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

References

  1. , . Granuloma annulare: Clinical and histologic variants, epidemiology, and genetics. J Am Acad Dermatol. 2016;75:457-65.
    [CrossRef] [PubMed] [Google Scholar]
  2. , . Granuloma annulare: Pathogenesis, disease associations and triggers, and therapeutic options. J Am Acad Dermatol. 2016;75:467-79.
    [CrossRef] [PubMed] [Google Scholar]
  3. , . Granuloma annulare: A focused review of therapeutic options. Am J Clin Dermatol. 2018;19:333-44.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , . Dermoscopy of granuloma annulare: A clinical and histological correlation study. Dermatology. 2017;233:74-9.
    [CrossRef] [PubMed] [Google Scholar]
  5. , . Dermatoscopy of cutaneous granulomatous disorders. Indian Dermatol Online J. 2021;12:34-44.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , , , et al. Dermoscopy of chondrodermatitis nodularis helicis. Arch Dermatol Res. 2018;310:551-60.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , . Bilateral granuloma annulare of the external ear. Eur J Dermatol. 2010;20:409-10.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , , , , , et al. Auricular granuloma annulare in a child. Int J Dermatol. 2014;53:e218-220.
    [CrossRef] [PubMed] [Google Scholar]
  9. , . Granuloma annulare of both pavillions of the ear. Actas Dermosifiliogr. 1954;45:405-6.
    [PubMed] [Google Scholar]
  10. , . Auricular granuloma annulare. A consequence of trauma? Am J Dermatopathol. 1992;14:431-3.
    [CrossRef] [PubMed] [Google Scholar]
  11. . Nodules of the external ear. Ann Dermatol Venereol. 1999;126:261-6.
    [PubMed] [Google Scholar]
  12. , , , . Perforating granuloma annulare presenting on the ears. Br J Dermatol. 2002;147:1026-8.
    [CrossRef] [PubMed] [Google Scholar]
  13. , , . Granuloma annulare presenting as multiple nodules on the pinna. J Laryngol Otol. 2004;118:640-2.
    [CrossRef] [PubMed] [Google Scholar]
  14. , , . A case of atypical granuloma annulare involving both ears. Ann Dermatol. 2009;21:413-5.
    [CrossRef] [PubMed] [Google Scholar]
  15. , , , . Relapsing papules on the antihelix of the left ear. Granuloma annulare (GA) JAMA Otolaryngol Head Neck Surg. 2013;139:1071-2.
    [CrossRef] [PubMed] [Google Scholar]
  16. , , , , , , et al. Auricular granuloma annulare induced by repeated occupational traumas. Korean J Dermatol. 2010;48:616-9.
    [Google Scholar]
  17. , , , , . Clinicopathologic features of rheumatoid nodules: A retrospective analysis. Clin Rheumatol. 2019;38:3041-8.
    [CrossRef] [PubMed] [Google Scholar]
  18. , . Chondrodermatitis nodularis helicis: A review of current therapies. Dermatol Ther. 2017;30
    [CrossRef] [PubMed] [Google Scholar]
  19. , , , . Auricular pseudocyst: Sonographic appearance in 17 patients. Ultrasound Q. 2020;37:370-3.
    [CrossRef] [PubMed] [Google Scholar]
  20. , . Sarcoidosis. Semin Ophthalmol. 2005;20:177-82.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
6,628

PDF downloads
2,453
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections