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Subcutaneous granuloma annulare of the finger
Subcutaneous granuloma annul are of the finger Granuloma annulare is a cutaneous disorder, which may be associated with subcutaneous fibrosis. Subcutaneous granuloma annulare lesions may occur without the cutaneous manifestations, and often biopsy is required for diagnosis. We report subcutaneous granuloma annulare of the index finger without cutaneous manifestations, in a 19-year-old woman. Diagnosis was confirmed by excision and histologic examination. In the natural history of granuloma annulare, a spontaneous. resolution can be expected. No other specific treatment is necessary. (J HAND SURG llA:429-31, 1986.)
James A. Wilkes, M.D., and James J. Hill, Jr., M.D., Springfield, Ill.
Granuloma annulare is an uncommon benign dermatosis that was first described in 1895 by Fox l and was named in 1902 by Crocker.2 The lesions are papules that partially coalesce to form circles. The histologic diagnosis is best made under low-power magnification where mononuclear cells are seen in a palisade surrounding foci of altered collagen. 3 Electron microscopic examination of granuloma annulare shows the collagen fibrils to be ill defined and disintegrated. 3 Fibrous tissue replaces fat cells,4 and perivascular lymphocytic infiltration is also seen. 3 The diagnosis of granuloma annulare is made by clinical examination. The patient may have cutaneous involvement or subcutaneous nodules. Biopsy may be required to establish the diagnosis. Wells and Smith5 reported 179 cases of granuloma annulare. There were 90 patients with single lesions and 89 patients with multiple lesions. They also reported that the lesions were isolated on the hands and arms in 63% of the patients, the feet and legs in 20%, the trunk in 5%, and combinations of these sites in 12%. Of the patients, 67% were under 30 years of age and they were usually healthy.4, 5 Spontaneous resolution is the expected outcome; yet one patient still has the lesion after 25 years. 5 Recurrence can be expected in 40% of the patients, usually From the Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, Springfield, Ill. Received for publication June 24, 1985; accepted in revised form Sept, 12, 1985. Reprint requests: James A. Wilkes, M.D., Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 800 N. Rutledge St., Springfield, IL 62781.
at the same site as the initial lesion. 3 , 5 However, the recurrences can be expected to resolve more rapidly than the original lesion (80% versus 50% clearance within 2 years).5 This report documents a case of a large, rapidly growing subcutaneous granuloma annu1are without superficial skin changes.
Case report In January 1984 a 19-year-old white woman was first seen with a mass on the palmar aspect of her right index finger. The mass had been present for 4 months and had been enlarging rapidly. It had become tender and painful and was restricting motion. There was no history of trauma, The mass was located on the radial aspect of the index finger from the proximal phalanx and extended over the middle phalanx; it measured 2.5 cm by l.0 cm (Figs. 1 and 2). The mass was diffuse and firm but did not adhere to either the tendon or the bone. Other than a slight discoloration of the overlying skin, there were no cutaneous manifestations, Doppler examination revealed that the radial digital artery was displaced dorsally in the region of the mass; no bruits were present. Radiographs showed a soft tissue mass without involvement ofthe bone. Since the mass was growing rapidly and was painful, excisional biopsy was recommended. The preoperative diagnosis was fibrous tumor of unknown causes. At operation the mass was found to be diffuse, and its boundaries were difficult to identify. The mass was wrapped around the radial neurovascular bundle of the index finger and adhered to the overlying dermis. A small specimen was obtained for frozen section and histologic examination, The specimen was interpreted as nonspecific fibrosis with a focus of necrosis, The mass was then carefully dissected free from the neurovascular bundle, the adherent dermis, and the flexor tendon sheath, Histologic examination showed adipose and fibrous tissue with many foci of necrosis surrounded by palisaded epitheliod cells, The intervening tissue was composed of dense fibrous tissue with chronic· inflammation. There was
THE JOURNAL OF HAND SURGERY
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430
Wilkes and Hill, Jr.
Fig. 1. The uninvolved left index: finger is shown above and the involved right index: finger is below, showing the difference in diameter.
The Journal of HAND SURGERY
Fig. 2. The palmar aspect of the right index: finger.
Fig. 3. Photomicrograph of the specimen shows a focus of necrosis surrounded by palisaded epithelioid cells . (Original magnification x 61.) no evidence of neoplasm. Findings were consistent with nodules of granuloma annulare. A photomicrograph of the histologic specimen appears in Fig . 3. At 2 months the wound had healed well. At 6 months the mass had begun to recur. Treatment consisted of applications of topical betamethasone dipropionate (Diprosone 0.05%), and the lesion finally resolved in 8 months .
Discussion Granuloma annulare is usually an erythematous patch, and it can evolve early into a pale, dome-shaped papule that is 1 to 2 mm in diameter. 3. 4 Several papules erupt and partially fuse to form a ring within the dermis.
The surface may show telangiectasia, which results from microscopic necrosis within the lesion. 4 Granuloma annulare occurs more frequently in females than in males. Wells and Smith~ report a 2.2 to 1 femaleto-male ratio. Lesions have been reported in twins, in siblings, and in successive generations. 3,5 Patients may have subcutaneous nodules as well as superficial papular lesions . The frequency of occurrence of subcutaneous nodules is not known. About one fourth of the patients who have subcutaneous nodules also have superficial lesions.3 The deeper lesions have a firmer consistency and are often close to the bone without adherence to
Vol. l1A, No.3 May 1986
the periosteum. 4 Subcutaneous nodules are found on the palms, legs, buttocks, and scalp. 4. 6 These locations have led to the theory that trauma may be a contributing factor6; however, the causes remain unknown. Guill and Goette 7 reported granuloma annulare that occurred at the sites of healing herpes zoster; this suggests a possible viral cause. The nodule of subcutaneous granuloma annulare is identical to the pseudorheumatoid nodules of childhood. 4 Both lesions occur in similar sites and have identical histories. 3 Children with lesions of granuloma annulare or pseudorheumatoid nodule of childhood are not likely to have significant arthritis. 3 , 8 Spontaneous resolution is the expected outcome for granuloma annulare. The lesions may persist for a few weeks to more than several decades; however, spontaneous resolution can be anticipated in 50% of the patients within 2 years. 3 , 5 Lesions recur in 40% of the patients, usually at the same site. Of these, 80% resolve in 2 years. 3 Therefore, treatment is usually not needed.
Subcutaneous granuloma annulare of finger
Many treatment modalities have been used, but they have not proved to be of significant benefit. REFERENCES 1. Fox TC: Ringed eruption of the fingers, Br J Dennatol 7:91-2, 1895 2. Selmanowitz VJ, Vandow JE, Director W: Atypical granuloma annulare. Arch Dermatol 93:454-6, 1966 3. Muhlbauer JE: Granuloma annulare. JAm Acad Dermatol 3:217-30, 1980 4. Rubin M, Lynch FW: Subcutaneous granuloma annulare. Arch Dennatol 93:416-20, 1966 5. Wells RS, Smith MA: The natural history of granuloma annulare. Br J Dennatol 75:199-205, 1963 6. Stillians AW: An unusual case of granuloma annulare. J Cutan Dis 37:580, 1919 7. Guill MA, Goette DK: Granuloma annulare at sites of healing zoster, Arch Dermatol 114:1383, 1978 8. Simmons FER, Schaller JG: Benign rheumatoid nodules. Pediatrics 56:29-33, 1975
Sporothrix schencKii tenosynovitis: A case report Sporothrix schencliii is a fungus known to cause infection of skin in the subcutaneous tissues. In this case tenosynovitis was caused by sporotrichosis resulting in rupture of the extensor tendon. Excision of the involved tenosynovium and repair of the tendons were done. Five months of oral medication with ketoconazole, 400 mg daily, led to resolution ofthe synovial disease and regression of a 1 cm pulmonary nodule found on It routine chest x ray film. (J HAND SURG llA:431-4, 1986.)
Edward L. Hay, M.D., Sherry S. Collawn, M.D., and Francis G. Middleton, M.D., Charleston, S.C.
Sporothrix schenc/(;ii is a dimorphic fun-
gus that causes an unusual infection most often produced by direct inoculation of the organism into the skin or subcutaneous tissue of the hand. The fungus is ubiquitous, growing especially well in soils associated with decaying vegetation. Rose thorns are a rich source of the organism. The most common clinical syndrome From the Departments of Orthopaedic Surgery, Plastic Surgery, and Medicine, Medical University of South Carolina, Charleston, S.C. Received for publication Nov. 16, 1984; accepted in revised form Sept. 9, 1985. Reprint requests: Edward L. Hay, M.D., Hand Surgery Associates, 30 Bee St., Charleston, SC 29403.
is a lymphocutaneous infection, I with a papule developing at the site of the inoculation, often associated with metastatic lesions along lymphatic channels and subsequent ulceration of these lesions. The infection has been reported in bones, joints, and tendon synovium. 2•8 Pulmonary involvement has also been reported. 9 • 14 The condition has been reported in florists. 15 We describe an unusual presentation of sporotrichosis causing tenosynovitis with rupture of the extensor tendons.
Case report A 73-year-old white man was first seen in the office in May 1981 complaining of pain in the right wrist. Three THE JOURNAL OF HAND SURGERY
431
James A. Wilkes, M.D., and James J. Hill, Jr., M.D., Springfield, Ill.
Granuloma annulare is an uncommon benign dermatosis that was first described in 1895 by Fox l and was named in 1902 by Crocker.2 The lesions are papules that partially coalesce to form circles. The histologic diagnosis is best made under low-power magnification where mononuclear cells are seen in a palisade surrounding foci of altered collagen. 3 Electron microscopic examination of granuloma annulare shows the collagen fibrils to be ill defined and disintegrated. 3 Fibrous tissue replaces fat cells,4 and perivascular lymphocytic infiltration is also seen. 3 The diagnosis of granuloma annulare is made by clinical examination. The patient may have cutaneous involvement or subcutaneous nodules. Biopsy may be required to establish the diagnosis. Wells and Smith5 reported 179 cases of granuloma annulare. There were 90 patients with single lesions and 89 patients with multiple lesions. They also reported that the lesions were isolated on the hands and arms in 63% of the patients, the feet and legs in 20%, the trunk in 5%, and combinations of these sites in 12%. Of the patients, 67% were under 30 years of age and they were usually healthy.4, 5 Spontaneous resolution is the expected outcome; yet one patient still has the lesion after 25 years. 5 Recurrence can be expected in 40% of the patients, usually From the Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, Springfield, Ill. Received for publication June 24, 1985; accepted in revised form Sept, 12, 1985. Reprint requests: James A. Wilkes, M.D., Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 800 N. Rutledge St., Springfield, IL 62781.
at the same site as the initial lesion. 3 , 5 However, the recurrences can be expected to resolve more rapidly than the original lesion (80% versus 50% clearance within 2 years).5 This report documents a case of a large, rapidly growing subcutaneous granuloma annu1are without superficial skin changes.
Case report In January 1984 a 19-year-old white woman was first seen with a mass on the palmar aspect of her right index finger. The mass had been present for 4 months and had been enlarging rapidly. It had become tender and painful and was restricting motion. There was no history of trauma, The mass was located on the radial aspect of the index finger from the proximal phalanx and extended over the middle phalanx; it measured 2.5 cm by l.0 cm (Figs. 1 and 2). The mass was diffuse and firm but did not adhere to either the tendon or the bone. Other than a slight discoloration of the overlying skin, there were no cutaneous manifestations, Doppler examination revealed that the radial digital artery was displaced dorsally in the region of the mass; no bruits were present. Radiographs showed a soft tissue mass without involvement ofthe bone. Since the mass was growing rapidly and was painful, excisional biopsy was recommended. The preoperative diagnosis was fibrous tumor of unknown causes. At operation the mass was found to be diffuse, and its boundaries were difficult to identify. The mass was wrapped around the radial neurovascular bundle of the index finger and adhered to the overlying dermis. A small specimen was obtained for frozen section and histologic examination, The specimen was interpreted as nonspecific fibrosis with a focus of necrosis, The mass was then carefully dissected free from the neurovascular bundle, the adherent dermis, and the flexor tendon sheath, Histologic examination showed adipose and fibrous tissue with many foci of necrosis surrounded by palisaded epitheliod cells, The intervening tissue was composed of dense fibrous tissue with chronic· inflammation. There was
THE JOURNAL OF HAND SURGERY
429
430
Wilkes and Hill, Jr.
Fig. 1. The uninvolved left index: finger is shown above and the involved right index: finger is below, showing the difference in diameter.
The Journal of HAND SURGERY
Fig. 2. The palmar aspect of the right index: finger.
Fig. 3. Photomicrograph of the specimen shows a focus of necrosis surrounded by palisaded epithelioid cells . (Original magnification x 61.) no evidence of neoplasm. Findings were consistent with nodules of granuloma annulare. A photomicrograph of the histologic specimen appears in Fig . 3. At 2 months the wound had healed well. At 6 months the mass had begun to recur. Treatment consisted of applications of topical betamethasone dipropionate (Diprosone 0.05%), and the lesion finally resolved in 8 months .
Discussion Granuloma annulare is usually an erythematous patch, and it can evolve early into a pale, dome-shaped papule that is 1 to 2 mm in diameter. 3. 4 Several papules erupt and partially fuse to form a ring within the dermis.
The surface may show telangiectasia, which results from microscopic necrosis within the lesion. 4 Granuloma annulare occurs more frequently in females than in males. Wells and Smith~ report a 2.2 to 1 femaleto-male ratio. Lesions have been reported in twins, in siblings, and in successive generations. 3,5 Patients may have subcutaneous nodules as well as superficial papular lesions . The frequency of occurrence of subcutaneous nodules is not known. About one fourth of the patients who have subcutaneous nodules also have superficial lesions.3 The deeper lesions have a firmer consistency and are often close to the bone without adherence to
Vol. l1A, No.3 May 1986
the periosteum. 4 Subcutaneous nodules are found on the palms, legs, buttocks, and scalp. 4. 6 These locations have led to the theory that trauma may be a contributing factor6; however, the causes remain unknown. Guill and Goette 7 reported granuloma annulare that occurred at the sites of healing herpes zoster; this suggests a possible viral cause. The nodule of subcutaneous granuloma annulare is identical to the pseudorheumatoid nodules of childhood. 4 Both lesions occur in similar sites and have identical histories. 3 Children with lesions of granuloma annulare or pseudorheumatoid nodule of childhood are not likely to have significant arthritis. 3 , 8 Spontaneous resolution is the expected outcome for granuloma annulare. The lesions may persist for a few weeks to more than several decades; however, spontaneous resolution can be anticipated in 50% of the patients within 2 years. 3 , 5 Lesions recur in 40% of the patients, usually at the same site. Of these, 80% resolve in 2 years. 3 Therefore, treatment is usually not needed.
Subcutaneous granuloma annulare of finger
Many treatment modalities have been used, but they have not proved to be of significant benefit. REFERENCES 1. Fox TC: Ringed eruption of the fingers, Br J Dennatol 7:91-2, 1895 2. Selmanowitz VJ, Vandow JE, Director W: Atypical granuloma annulare. Arch Dermatol 93:454-6, 1966 3. Muhlbauer JE: Granuloma annulare. JAm Acad Dermatol 3:217-30, 1980 4. Rubin M, Lynch FW: Subcutaneous granuloma annulare. Arch Dennatol 93:416-20, 1966 5. Wells RS, Smith MA: The natural history of granuloma annulare. Br J Dennatol 75:199-205, 1963 6. Stillians AW: An unusual case of granuloma annulare. J Cutan Dis 37:580, 1919 7. Guill MA, Goette DK: Granuloma annulare at sites of healing zoster, Arch Dermatol 114:1383, 1978 8. Simmons FER, Schaller JG: Benign rheumatoid nodules. Pediatrics 56:29-33, 1975
Sporothrix schencKii tenosynovitis: A case report Sporothrix schencliii is a fungus known to cause infection of skin in the subcutaneous tissues. In this case tenosynovitis was caused by sporotrichosis resulting in rupture of the extensor tendon. Excision of the involved tenosynovium and repair of the tendons were done. Five months of oral medication with ketoconazole, 400 mg daily, led to resolution ofthe synovial disease and regression of a 1 cm pulmonary nodule found on It routine chest x ray film. (J HAND SURG llA:431-4, 1986.)
Edward L. Hay, M.D., Sherry S. Collawn, M.D., and Francis G. Middleton, M.D., Charleston, S.C.
Sporothrix schenc/(;ii is a dimorphic fun-
gus that causes an unusual infection most often produced by direct inoculation of the organism into the skin or subcutaneous tissue of the hand. The fungus is ubiquitous, growing especially well in soils associated with decaying vegetation. Rose thorns are a rich source of the organism. The most common clinical syndrome From the Departments of Orthopaedic Surgery, Plastic Surgery, and Medicine, Medical University of South Carolina, Charleston, S.C. Received for publication Nov. 16, 1984; accepted in revised form Sept. 9, 1985. Reprint requests: Edward L. Hay, M.D., Hand Surgery Associates, 30 Bee St., Charleston, SC 29403.
is a lymphocutaneous infection, I with a papule developing at the site of the inoculation, often associated with metastatic lesions along lymphatic channels and subsequent ulceration of these lesions. The infection has been reported in bones, joints, and tendon synovium. 2•8 Pulmonary involvement has also been reported. 9 • 14 The condition has been reported in florists. 15 We describe an unusual presentation of sporotrichosis causing tenosynovitis with rupture of the extensor tendons.
Case report A 73-year-old white man was first seen in the office in May 1981 complaining of pain in the right wrist. Three THE JOURNAL OF HAND SURGERY
431