Photo Quiz

Recalcitrant Annular Rash


Am Fam Physician. 2021 Oct ;104(4):415-416.

A 71-year-old patient presented to the family medicine office for routine preventive care. The patient reported having a rash that developed one month earlier. The rash appeared spontaneously and was not associated with systemic symptoms, such as fevers or chills. The patient did not have photosensitivity.

The patient had no relevant contact exposures, including new personal hygiene or cleaning products, and was not taking any new medications. The patient did not have a history of dermatologic disease, diabetes mellitus, or known malignancy.

Physical examination revealed a pruritic, nonscaly, ring-like rash, mostly localized on the dorsa of both hands (Figure 1). Based on clinical appearance, the patient was empirically treated for a dermatophyte infection, but the rash persisted and spread to the forearms (Figure 2). A punch biopsy of the lesion on the hand was performed.






Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Erythema annulare centrifugum.

  • B. Granuloma annulare.

  • C. Subacute cutaneous lupus erythematosus.

  • D. Tinea corporis.


The answer is B: granuloma annulare, a benign, idiopathic, granulomatous skin disease that is more common in women. Granuloma annulare can be localized or generalized. Localized granuloma annulare occurs most often on the dorsal or lateral surfaces of the hands or feet. The lesions present as nonscaly, skin-colored or erythematous, annular plaques with a firm, rope-like border and central clearing. Generalized granuloma annulare presents as multiple widespread, skin-colored to erythematous papules and plaques that vary in size and predominately occur on the trunk and extremities. Granuloma annulare can be distinguished from other annular skin conditions by the lack of scaling or other surface changes to the skin. The localized type is more common in younger adults, whereas generalized granuloma annulare has a bimodal distribution.13

Localized granuloma annulare is likely to resolve spontaneously within months or a few years, but the generalized form is more chronic and less responsive to treatment. The literature on treatment is limited to case reports and small uncontrolled studies. Typical treatments include topical therapies, systemic immunosuppressive therapies, and phototherapy. High-dose systemic steroids have been shown to be beneficial; however, symptoms often recur after discontinuation of treatment. The exact cause of the condition is unclear, but potential associations have been reported between both types of granuloma annulare and diabetes mellitus, thyroid disease, hyperlipidemia, malignancy, insect bites, and viral disease.13

Erythema annulare centrifugum is a delayed-type hypersensitivity reaction manifesting as annular, erythematous plaques with a trailing rim of scale. A paraneoplastic erythema annulare centrifugum eruption may also occur, with an erythematous lesion and urticarial type papules that enlarge centrifugally and then clear centrally.4

Subacute cutaneous lupus erythematosus is often associated with

Author disclosure: No relevant financial affiliations.

Address correspondence to Michael Layne, MD, at


show all references

1. Lukács J, Schliemann S, Elsner P. Treatment of generalized granuloma annulare - a systematic review. J Eur Acad Dermatol Venereol. 2015;29(8):1467–1480....

2. Cyr PR. Diagnosis and management of granuloma annulare. Am Fam Physician. 2006;74(10):1729–1734. Accessed August 29, 2021.

3. Thornsberry LA, English JC III. Etiology, diagnosis, and therapeutic management of granuloma annulare: an update. Am J Clin Dermatol. 2013;14(4):279–290.

4. McDaniel B. Erythema annulare centrifugum. StatPearls. Updated August 27, 2021. Accessed August 31, 2021.

5. Kuhn A, Landmann A. The classification and diagnosis of cutaneous lupus erythematosus. J Autoimmun. 2014;48–49:14–19.

6. Jatwani S. Subacute cutaneous lupus erythematosus. StatPearls. Updated August 9, 2021. Accessed August 31, 2021.

7. Leung AK, Lam JM, Leong KF, et al. Tinea corporis: an updated review. Drugs Context. 2020;9:2020-5-6.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of Photo Quiz published in AFP is available at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to



Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content


May 2022

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article