Generalized Granuloma Annulare Treated with Monthly Rifampicin, Ofloxacin, and Minocycline Combination Therapy
A 52-year-old woman presented with complaints of multiple asymptomatic skin-colored raised lesions on the trunk and extremities of 6 months duration, which were insidious in onset and progressive in nature, with the last lesion appearing 1 month back. Patient was a diagnosed case of Type 2 diabetes mellitus (DM) and rheumatoid arthritis (RA) since 2008, for which she was on regular treatment with tablet metformin 500 mg TDS, tablet glimipride 1 mg daily, tablet hydroxychloroquine 200 mg BD, tablet methotrexate 5-7.5 mg per week (total cumulative dose of methotrexate till now being 1300 mg), and tablet folic acid 5 mg taken daily except on the days of taking methotrexate. There was no history of photosensitivity.\nDermatological examination revealed the presence of multiple well-defined skin-colored to slightly erythematous papules coalescing to form well-defined plaques, few being annular in configuration, present on the flexor aspect of right forearm near the elbow joint, flexor and extensor aspects of left forearm near the elbow joint [], left upper arm, chest, and abdomen. The individual papules forming the plaques had elevated borders with depressed centers. The lesions were normoasthetic on examination. Rest of the general and systemic examinations were within normal limits.\nThe results of her complete blood count, erythrocyte sedimentation rate, liver and kidney function tests were within normal limits. Fasting blood sugar was 95 mg/dl and postprandial blood sugar was 124 mg/dl, which were essentially within normal limits. Histopathologic examination was suggestive of GA. There was mild thinning of the epidermis with dermis showing histiocytes arranged in interstitial pattern, presence of multinucleate giant cells, and mild perivascular lymphocytic infiltrate with no collagen necrosis [].\nBased on the dermatological examination and histopathologic findings, the diagnosis of GA was made. The patient was treated with single dose of rifampicin 600 mg, ofloxacin 400 mg, and minocycline 100 mg (ROM) given once a month for 5 months. Patient tolerated the combination therapy well with no side effects. All the lesions subsided after 5 months of monthly ROM, leaving behind slight epidermal atrophy of skin at few sites []. There was no recurrence at 3 months of follow-up.