Can Simultaneous Psoriasis and Granuloma Annulare Annihilate Each Other?

In a previous post on this blog, I reported a patient who had psoriasis, granuloma annulare (GA), and alopecia areata. I recently saw two more cases where psoriasis was coincidentally associated with GA.

Case 1. A middle-aged lady was referred by her primary care doctor for a rash on the legs. Some of the spots were red and scaly, but others were red but smooth and showed some clearing in the center. Naturally, I thought that psoriasis, eczema, and fungal infection were possible, but also had to consider GA and cutaneous T-cell lymphoma.

I performed skin biopsies on two lesions that had these different characteristics, even though they were very close together. One biopsy showed psoriasis, the other, GA. When the patient returned for the report, we considered therapies that might help both skin diseases, for example, a potent topical steroid or ultra-violet light therapy. She thoughtfully asked, what would happen when the two diseases met, since they were already in such close proximity on her legs. I answered, admittedly tongue-in-cheek, that perhaps they would neutralize each other because they are the result of different types of inflammation in the skin.

Here’s a little science: you can skip to the next paragraph if you want to get to the clinical outcome. Psoriasis of course is quite common, affecting about 2.5% of US persons. It is believed to have a genetic basis that leads to a type of inflammation in skin and joints caused by T-helper-17 white blood cells. GA, on the other hand, is much less common and is considered to be an allergic reaction to some unknown antigen, sometimes bug bites, that leads to inflammation in skin caused by T-helper 1 white blood cells. In the case of psoriasis, the inflammation results in the rapid growth of skin cells in the epidermis. In the case of GA, the inflammation leads to the gradual degradation of the connective tissue (collagen and elastin) in the dermis, which is below the epidermis.

Short story: clobetasol ointment cleared both diseases from the legs.

Longer, more realistic, complicated story: The two skin diseases seemed to “retreat” from the therapy. After the legs cleared, she developed typical red scaly psoriasis patches on the soles of her feet. I treated this with bath-PUVA which was partially successful. Later, new classic ring-like lesions appeared on her back. Since these were not causing any symptoms and she couldn’t see or reach them, we decided not to treat.

Case 2. I encountered another case of the coexistence of psoriasis and generalized granuloma annulare (GA). This patient reported that when her psoriasis was treated with the injectable biologic drug called Humira, the GA also cleared.

Comment: It is known that there are elevated levels of an inflammatory chemical called tumor necrosis factor (TNF) in the skin of psoriasis and in the joints of psoriatic arthritis. Humira is an antibody that blocks the effects of TNF. We don’t know the cause of GA, but perhaps TNF plays a role in the inflammation of the skin in this disease too.

Read this post on Coexistence of Autoimmune Diseases


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8 Responses to Can Simultaneous Psoriasis and Granuloma Annulare Annihilate Each Other?

  1. Eldean Madden says:

    Dr. Camisa:
    Have you tried or considered trying Humira for GA patients who have no other skin issues?

    • Dr. Camisa says:

      No, I haven’t, mostly because the risks of Humira would outweigh the benefits to GA. Moreover, insurance would most likely not cover it because Humira is not FDA-approved for GA.

  2. Kirsten says:

    I have psoriasis and ga. Have you ever found treatment that helps? Very depressing. It keeps getting worse.

    • Dr. Camisa says:

      Yes, but the 2 diseases have to be treated separately with different meds. Please consult your dermatologist.

  3. Kira Miftari says:

    Hello Dr. Camisa… I read through your blog and contacted your office looking for a referral in /around Orange County, CA… Your amazing assistant called back today and suggested that I leave a comment on your last blog post…
    For the last 5 years I have a weird condition where my fingers swell, to the point of not being able to bend them, and stay that way anywhere from 1,5 months to 3 months… I then have around a month-2 break, and then it comes back… Visually, it resembles Chilblains (I don’t have sores though and the duration doesn’t match)…
    I did consult a rheumatologist (UC Irvine) and a Immunologist (who said I have very low immune status) but they had no clue what is going on…only confirmed it is not RA.
    I am struggling to find a Dermatologist (or a Rheumatologist) with your scope of knowledge, they are mostly interested in moles and cosmetic procedures, and not knowledgeable, for example, of skin manifestations of autoimmune conditions and other systemic condition…
    I certainly wish I lived in your area, but since I don’t – I would greatly appreciate if you could refer me to a Doctor (Dermatologist and/or Rheumatologist) that you believe has a scope of experience, interest and knowledge to tackle a problem that others have failed to tackle…
    Thank you in advance!

    • Dr. Camisa says:

      Thank you for your question and for your kind comments about Chrissy. Your condition sounds unusual and of course would be almost impossible to diagnose without seeing it in action. I have a couple of suggestions for you to look up. There’s a group of rare conditions called relapsing febrile diseases such as Mediterranean Fever. Erythromelalgia is another possibility. Mayo Clinic and NORD websites are reliable resources.
      I would suggest taking good photos of both sides of your hands during an outbreak and measuring and recording your body temp throughout the day or daily if it persists. Make an appointment to the Derm Dept of one of the major university hospitals in your area such as UCLA, USC, UCDavis, telling them what you think it might be. Bring your photos and temp charts to the appointment. If at all possible, I also recommend consultation with Mayo Clinic in Rochester, MN because they have published on these rare entities. Let me know how it turns out.

  4. I have had GA on my upper legs for several years which I treat with Plaquenil tabs and Clobetasol Cream. It clears somewhat and then gets worse again—never completely clear. I have had the Shingles for 3 -1/2 months with large blisters initially and severe pain. I have been treated with various drugs. This is on my right shoulder, upper back, neck and upper chest. The original rash has cleared but I broke out with a different looking rash with small blisters that itch constantly. The pain continues mostly on my chest around the main artery across this area. My Dermatologist did 2 biopsies 10 days ago. The results showed no infection or viruses. I continue to use Clobetasol Cream, Plaquenil tabs and a compound cream (Amit2%Gaba6%Ketam5% for the burning pain. The Dermatologist says the new rash is GA brought on by the Shingles but it doesn’t look like the rash on my legs. I never had blisters on my legs. What do you think this could be?

    • Dr. Camisa says:

      I have seen GA develop in areas of shingles, but without more information, I would not be able to answer what else it could be.

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