Generalized pearly white papular lesions in a 3 year old child

A 3-year-old female child presented with multiple asymptomatic solid raised lesions all over body since 8 months. There was no history of similar lesions in family members. Cutaneous examination revealed generalized, bilaterally symmetrical, multiple, discrete, well-defined pearly white papular lesions over face, neck, back, knees, elbow, and dorsum of hands [Figures 1 and 2]. Few papular lesions over dorsum of hands revealed central clearing with well-defined raised border [Figure 3]. Systemic examination findings were within normal limits. Routine hematological investigations including blood sugar levels and lipid profile were within the normal limits. Enzyme linked immuno sorbent assay test for Human immuno deficiency virus antibodies was negative. Skin biopsy from papular lesion revealed focal areas of collagen degeneration with mucin deposits surrounded by palisading arrangement of histiocytes with few multinucleated giant cells in peripheral zone involving upper dermis [Figures 4 and 5]. The patient was diagnosed to be a case of generalized granuloma annulare (GGA) based on the histopathological findings, which was not thought clinically. Patient was treated with topical corticosteroid with a moderate improvement at the end of 3 weeks.

Figure 1.

Discrete pearly white papules over neck and upper back

Figure 2.

Pearly white dome shaped papules over dorsum of hands

Figure 3.

Papular lesions with central clearing over dorsum of hand

Figure 4.

Focal areas of collagen degeneration with palisading arrangement of histiocytes involving upper dermis (H and E, ×10)

Figure 5.

Palisading arrangement of histiocytes with few multinucleated giant cells in peripheral zone involving upper dermis (H and E, ×40)

Granuloma annulare can occur at any age with female predominance.[1] GGA usually occurs in adults and rarely in infants and childhood. GGA is characterized by a later age of onset, a wide distribution of lesions, a chronic course with only rare spontaneous resolution and a poor response to therapy compared with the localized type.[1,2]

There are paucity of foreign reports regarding clinical presentation of GGA in infancy and childhood.

GGA has been reported as early at the age ranging from 3 to 5 months from Korea and at an age of 7 months from Japan.[3,4,5]

There were case reports of GGA following bacillus calmette-guerin (BCG) vaccination and insect bite.[6,7,8]

The pathogenensis of GGA has not been fully understood, the presence of activated T-cells in GA suggests that cell-mediated immunity plays a role. It has been reported that GA occurred in association with trauma, insect bite, sun exposure, virus infection and BCG vaccination.[2,8]

Patients with GGA characteristically present with few to thousands of 1-to 2-mm papules or nodules, skin colored to erythematous involving trunk and extrimities. Papules may enlarge centrifugally to form annular plaque over weeks to months.

Close differential diagnostic conditions, which were ruled out histopathologically includes Lichen nitidus, Papular xanthoma, Molluscum contagiosum and interstitial granulomatous dermatitis.