Derm Cases · Dermatology / Endocrinology
OSCE — annular plaques on the hands: diagnose granuloma annulare and screen when generalised
An 8-minute OSCE station on localised vs generalised granuloma annulare, palisading granuloma with mucin histology, differentials of annular lesions, diabetes/metabolic screening in disseminated disease, and stepwise therapy.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on localised vs generalised granuloma annulare, palisading granuloma with mucin histology, differentials of annular lesions, diabetes/metabolic screening in disseminated disease, and stepwise therapy.
Brief (to candidate)
A 28-year-old has asymptomatic annular plaques with a firm papular rim on the dorsa of both hands for 6 months. A second vignette is a 62-year-old with widespread annular and arcuate plaques on trunk and limbs. You have 8 minutes to diagnose granuloma annulare subtypes, separate key annular differentials, and plan investigation and treatment.
[1]Candidate instructions
- Describe classic localised GA morphology and sites.
- State the histological hallmark (palisading granuloma + mucin).
- Differentiate from tinea, annular lichen planus, sarcoid, erythema migrans, and necrobiosis lipoidica.
- Explain when to screen for diabetes/metabolic disease/HIV/malignancy.
- Outline therapy from observation/topicals to phototherapy/systemics for generalised disease.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Clinical | Localised GA: annular plaques with papular rim, often hands/feet/extensors; usually asymptomatic; self-limited over months–years common[1][5] |
| Histology | Palisading granulomas around central necrobiotic collagen + mucin; interstitial GA variant also recognised[2] |
| Subtypes | Localised, generalised/disseminated, subcutaneous (children), perforating, patch GA |
| Differentials | Tinea corporis (scale, KOH+), annular LP, cutaneous sarcoid, erythema migrans, NL (shins, yellow atrophy), annular elastolytic giant-cell granuloma[3] |
| Associations | Generalised/disseminated GA in adults → screen diabetes, lipids, thyroid, consider HIV and occult malignancy (esp. lymphoma) when indicated[6] |
| Therapy | Reassure and observe mild localised disease; high-potency topical/IL steroids; cryotherapy for few lesions; generalised: phototherapy, systemic options (e.g. antimalarials, isotretinoin, others) per refractory disease — evidence mixed, shared decisions[4] |
| Safety-net | Biopsy atypical/ulcerating/progressive lesions; treat and reassess annular scale for fungal disease |
Model key actions
- Diagnose localised GA from annular papular-rim plaques on acral sites without scale.[1]
- Name palisading granuloma with mucin as the histologic signature.[2]
- In generalised GA, screen metabolic disease and escalate therapy beyond topicals when symptomatic/extensive.[4][6]
Common errors
- Treating GA as tinea with prolonged antifungals without KOH/biopsy.
- Over-investigating simple localised self-limited disease in a healthy young adult.
- Missing metabolic/diabetes screen in disseminated older adult GA.
- Confusing GA with necrobiosis lipoidica on the shins.
- Promising guaranteed clearance with any single systemic agent.
References6ShowHide
- [1]Joshi TP, Duvic M. Granuloma Annulare: An Updated Review of Epidemiology, Pathogenesis, and Treatment Options. American Journal of Clinical Dermatology, 2022.PMID 34495491
- [2]Terziroli Beretta-Piccoli B, Mainetti C, Peeters MA, et al. Cutaneous Granulomatosis: a Comprehensive Review. Clinical Reviews in Allergy & Immunology, 2018.PMID 29352388
- [3]Trayes KP, Savage K, Studdiford JS. Annular Lesions: Diagnosis and Treatment. American Family Physician, 2018.PMID 30216021
- [4]Bettolini L, Maione V, Carugno A, et al. Management Strategies for Generalised Granuloma Annulare: A Systematic Review of Current and Emerging Therapies. Australasian Journal of Dermatology, 2025.PMID 40586485
- [5]Keimig EL. Granuloma Annulare. Dermatologic Clinics, 2015.PMID 26143416
- [6]Lima AL, Illing T, Schliemann S, et al. Cutaneous Manifestations of Diabetes Mellitus: A Review. American Journal of Clinical Dermatology, 2017.PMID 28374407