Grand Rounds

Itching for an answer: Managing a recurrent evolving annular rash in a teen girl

Benjamin N. Africk1, Bridget Boyd2,1
1Department of Pediatrics, Loyola University Chicago Stritch School of Medicine, 2Department of Pediatrics, Loyola University Medical Center, IL, USA

Address for Correspondence: Bridget Boyd, MD, Department of Pediatrics, Loyola University Medical Center, 2160 South 1st Avenue, Maywood, IL, 60153, USA. Email:

Keywords: Granuloma Annulare, Annular Lesions, Tinea Corporis, Nummular Eczema, Psoriasis

Clinical Problem:
A 13-year-old female with a history of atopy presented with a recurrent and worsening skin rash for 2 months (Figure 1). Around age 3 years, she developed a scaly, pink patch in the shape of a heart on her left dorsal foot. She was treated for tinea corporis with over-the-counter topical antifungal cream and hydrocortisone without response. A presumptive diagnosis of granuloma annulare was subsequently made and she was treated with desoximetasone 0.25% cream and halobetasol propionate 0.05% ointment for 6 months with no improvement. Parents stopped the topical steroids and the lesion resolved on its own several months later. It never itched or caused pain; it did not bother her. Over the next several years, the skin underneath the previous site became thicker and "lumpy." Examination at seven years old revealed a 1.5 cm subtle soft mobile subcutaneous nodule on the left dorsal foot. The lesion remained relatively unchanged until 2 months prior to presentation when she developed new slightly hyperpigmented “lumps” on her left foot. She described it as mildly pruritic. Although not painful, it was uncomfortable especially when wearing shoes and playing sports. Examination revealed multiple slightly violaceous soft mobile subcutaneous nodules extending down the left foot and persistence of the prior lesion.

Figure 1. Patient’s foot at age 13 years with new lesions. Red arrows indicate original lesion borders that presented at age 3 years.

What are the causes of annular skin lesions in the pediatric population and how to treat them?

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