Coexistence of 3 Autoimmune Diseases: Granuloma Annulare and Psoriasis and Alopecia Areata

A middle-aged woman consulted me for a rash on her palms and backs of hands for several years’ duration.  The rash consisted of smooth pinkish-red bumps on the knuckles and rings and arcs on the palms with central clearing. Curiously, when the two palms were held together side-by-side, incomplete arcs formed a full circle.  The previous Dermatologist’s skin biopsy showed granuloma annulare (please see my separate blog on this subject for more details).  He treated her with various topical steroids to no avail.

Because the hands are amenable to treatment with ultraviolet light which has immunomodulating and anti-inflammatory effects, I decided to treat her with a Psoralen soak followed by exposure to UVA light.  This treatment is called bath-PUVA.  Bath-PUVA is usually used to treat psoriasis, but it is also on the list of alternative therapy for resistant cases of granuloma annulare.  The soak with the dilute solution of psoralen lasts for about 15 minutes and serves to sensitize the skin to the UV light.  Our initial exposure with UVA is 30 seconds; we treat twice per week and increase the dose by 8 seconds per side each treatment.

The upper box was used to treat the hands and the lower box was used to treat the soles after the psoralen soaks.

After 12 treatments, there was 50% improvement, and by 24 treatments, greater than 90% clearance was observed.  We decided to stop the treatment at this point.  Six weeks later, the palms were completely clear, and the knuckles showed 2 small dots.

About a month later, the patient was referred back by her Dermatologist for a different problem.  The palms were still clear, but the soles were now red, thickened, and covered with white scales.  Testing for fungus gave negative results.  I performed  a skin biopsy which confirmed psoriasis.  We treated her soles with bath-PUVA, and she had an excellent response. She next developed patches of hair loss on the back of the scalp without any redness or scaling. The new diagnosis is Alopecia Areata. We have been treating this with local injections of triamcinolone, nearly all of the hair has regrown.

Typical pathology of psoriasis shows thickened and elongated epidermis with inflammation around superficial blood vessels

Typical pathology of psoriasis shows thickened and elongated epidermis with inflammation around superficial blood vessels

Comment:  This patient had three different skin diseases most likely on the basis of autoimmunity.  Autoimmune disease do tend to cluster in the same individual. The coexistence of granuloma annulare and psoriasis has been reported before.  However, I believe this is the first case where bath-PUVA was used successfully to treat both diseases in the same patient. I have also seen psoriasis and alopecia areata in the same patient but never all three diagnoses together.

Bath-PUVA is an extremely safe treatment choice for palm and sole skin.  The psoralen solution is so dilute that there is negligible absorption into the bloodstream.  Therefore, while the palm and sole skin is made more sensitive to the UVA light, the rest of the body skin and eyes are not affected.  The solution is simply washed off after the light exposure, and it is not necessary for the patient to wear sunglasses.  It is uncommon to get a burn from bath-PUVA because the thickened skin is protective, and skin cancer has not been reported as a result of such treatment.

Other Interesting Case Studies:
Psoriasis Associated with Plaquenil (Hydroxychloroquine)
Painful Oral Erosions and White Patches

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14 Responses to Coexistence of 3 Autoimmune Diseases: Granuloma Annulare and Psoriasis and Alopecia Areata

  1. James Elder says:

    please contact me when you have a chance. I would like to talk to you about your work with neutrophils and autologous serum in psoriasis that was published in the JID in April 1984.

    Hope all is well with you.

    BTW in searching your work I found that we are on one paper together, an NPF position paper on what constitutes moderate to severe psoriasis.

  2. Tracy Fittro says:

    I have both granuloma annulare and alopecia. I had my first outbreak 4 years ago. First I noticed the spots on the top of my feet then I noticed hair loss. I received injections for my hair loss and used a prescription strength cortizone cream for the spots. The spots took about 3 months to disappear and after a series of injections it took my hair about 6 months. This year in Feb the spots are back and my alopecia is out of control. I would love more info on the possible connection between these two issues.

  3. Denise Boyle says:

    Hi Dr Carisma
    I am wondering if you can help me but big problem is I live in Ireland, I need advise to tell my dermatologist as she doesn’t know and is not doing anything, I have an underactive thyroid, diagnosed 4 yrs ago, on armour for it, but I also have now granuloma annulare, hands and feet, seborreheic dermatitis (scalp) , seborreheic keratosis (small patches on face) and chronic hair loss, androgentic alopecia, I feel a mess and she said there is nothing she can do. Can you please advise me on what I can say, ie take printed matter to her, for treatment, I would love to come to you but finances are against 🙁 . I feel you are the only person that can help me. Denise

    • DrCamisa says:

      You have several medical conditions simultaneously that are not related. You could ask your dermatologist to look at my blog, but I think you need to get your general practitioner more involved as your advocate. If you need another dermatologist, perhaps the GP would be able to consult one of the excellent dermatology professors at the UK university hospitals.

  4. Mrs T says:

    My aunt has been diagnosed with granuloma…but she is experiencing severe pain and also has the circular rashes. She lives in the Tampa Florida area…she feels that her body is failing her..I’m trying to help her. Please email me if you’re able to help. I have a lot of information to give about her condition but its too long to type. Thank you

    • DrCamisa says:

      It would not be helpful to write more here. The Dermatology department at the University of South Florida has many excellent specialists who can probably help your aunt without having to travel so far. Granuloma annulare is usually not painful in my experience.

  5. GA Researcher says:

    Dr. Camisa,
    Do you know what Antigen is associated with GA that classifies it as Autoimmune? I’m working on a study and can’t find the associated antigen, anywhere.

    • DrCamisa says:

      You’re right. The antigens for GA are not known. We have a tendency in medicine to label diseases as autoimmune when their cause is simply unknown.

  6. GA Researcher says:

    According to the American Autoimmune Related Disease Association, “GA cannot be classified as Autoimmune until an associated antigen can be identified”. Calling it AI is confusing to those who have it, unless you are classifying it as “Undifferentiated”. Here is the list of known AI disorders:

  7. GA Researcher says:

    Why do pathologists classify all of the different types of GA with a generic ‘GA’ diagnosis? Someone with photosensitive Actinic GA is just told they have GA and is not told that they should avoid the sun or light therapy. Someone with Interstitial Drug Related form is not told that their medication may be causing it. They are just told that the diagnosis is GA. I was told I had GA 10 years ago, just to recently find out the pathology report’s narrative says Interstitial. This lack of doctor to patient information seems detrimental to the patient’s welfare. Is this just an accepted practice or can diagnosis codes be added to include all the different forms?

    • DrCamisa says:

      This is a very technical question, not sure if I can answer adequately because it involves dermatopathology and coding. Clinically, there are differences between actinic granuloma (not called GA by us) and interstitial GA compared to the more typical localized and generalized GA types. In my experience, interstitial GA is more difficult for the pathologists to diagnose with certainty. Some of these cases have turned out to be cutaneous T-cell lymphoma.

  8. Anne says:

    Ive also suffered from granuloma and alopecia but here in latinamerica they arent very familiar with the possibility of these two diseases attacking at the same time. Going to make my physician take a look at this blog and see if he can figure out how to help me. thanks doctor for your blog

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