Treatment of Granuloma Annulare
For localized granuloma annulare, apply mid to high potency topical corticosteroid ointment twice daily under occlusion, and for generalized disease, use narrowband UVB phototherapy as first-line treatment. 1, 2
Localized Disease Treatment Algorithm
Start with mid to high potency topical corticosteroid ointment applied twice daily under occlusion as the initial approach for localized lesions. 1, 2 This remains the standard first-line therapy recommended by the American Academy of Dermatology. 1
Second-Line Options for Persistent Localized Disease
Intralesional triamcinolone acetonide (5-10 mg/cc) should be used for lesions that fail initial topical therapy. 1, 2 This is particularly effective for stubborn, well-defined plaques.
Topical vitamin D analogs combined with topical steroids can be employed for lesions resistant to corticosteroids alone. 1, 2
Topical tacrolimus or pimecrolimus serve as alternative options for refractory localized disease. 1, 2
Liquid nitrogen cryotherapy represents another treatment modality for localized lesions. 3
Generalized/Disseminated Disease Treatment Algorithm
Narrowband UVB (TL-01) phototherapy is the first-line treatment for generalized granuloma annulare because it offers the most favorable long-term safety profile compared to other treatment modalities. 1, 2 This is the preferred approach over other phototherapy options.
Alternative Phototherapy
- Photodynamic therapy achieves a 52% complete response rate but is impractical for widespread disease due to treatment delivery challenges. 1, 2 This limits its utility despite reasonable efficacy.
Systemic Therapy for Refractory Generalized Disease
When phototherapy fails or is not feasible, multiple systemic options exist, though evidence is limited to case reports and small series:
Methotrexate has shown success in case reports for refractory disease. 1
Dapsone, isotretinoin, hydroxychloroquine, cyclosporine, pentoxifylline, and fumaric acid esters have all been reported as treatment options. 4, 3
Biologic agents including etanercept, infliximab, and adalimumab have been used in resistant cases. 4
Systemic corticosteroids can be considered for severe cases, particularly when associated with systemic manifestations. 5
Important Clinical Considerations
Regular follow-up to assess treatment response is necessary for all patients. 1, 2 This is critical because localized disease typically resolves within one to two years spontaneously, while disseminated disease persists longer. 3
Key Pitfalls to Avoid
Do not rush to treat localized disease aggressively, as it is self-limited and may only require reassurance. 3 However, treatment can be offered for cosmetic concerns or patient preference.
Avoid photodynamic therapy as a routine recommendation due to insufficient evidence and practical limitations for widespread disease. 1
Screen for diabetes mellitus in patients with granuloma annulare, particularly those with generalized disease, as this association is well-documented. 5, 6
Evidence Quality Note
The treatment recommendations are based primarily on expert opinion, case reports, and small case series rather than randomized controlled trials. 4, 3 Well-designed controlled studies are lacking for this condition, making guideline-based recommendations particularly valuable for clinical decision-making.