Case of Generalized Granuloma Annulare Treated with Low Dose Naltrexone + PUVA

Granuloma annulare (GA) is a common, noninfectious granulomatous skin condition that usually presents in its localized form, characterized by flesh-colored to erythematous papules coalescing into annular plaques without scale, commonly on the dorsal hands. Lesions can be pruritic and often resolve without treatment in two years. However, the generalized form of GA has a lower incidence and presents with similar morphology, but with >10 lesions in a widespread distribution. Generalized GA is known to be more symptomatic, longer-lasting, and recalcitrant to treatment. The diagnosis is made based on clinicopathological correlation with palisading granulomas around degenerated collagen in the dermis, mucin, and infiltrative lymphocytes and histiocytes. Treatment remains challenging as evidence is limited to case reports, case series, and a few retrospective studies. Here we present the case of a 59-year-old Caucasian female with pruritic rash that began on her abdomen and spread to her extremities over two months. Biopsy revealed superficial histiocytic infiltrates palisading around eosinophilic areas of altered collagen, multiple multinucleate giant cells with elastophagocytosis and lymphohistiocytic perivascular infiltrates, and mucin in the dermis on colloidal iron staining. Overall, this was consistent with generalized GA. The patient was started on a combination of low dose naltrexone (LDN) and psoralen and ultraviolet A (PUVA) therapy. At a five-month follow up visit, she demonstrated near complete resolution of symptoms without any serious adverse effects.