granuloma annulare ( ga ) is a common idiopathic disorder affecting the dermis and subcutaneous tissues . this benign dermatosis generally presents with generalized or localized lesions ; macular , patch , perforating , and subcutaneous ga have also been described . ulceration , while not a typical feature associated with ga , has been seen in the less common perforating variant . necrobiosis lipoidica ( nl ) is a rare chronic granulomatous disease characterized by erythematous papules or plaques that grow centrifugally , becoming brownish - yellow with central atrophy . the lesions are typically seen in the pretibial region , but can also appear on the face , penis , scalp , and trunk . delayed - type hypersensitivity has been postulated to cause ga [ 58 ] ; other authors mention vasculitis as a potential mechanism . microangiopathy has been suggested to play a role in the etiology and pathogenesis of nl . while differences exist , both dermatoses share similarities including an association with diabetes , similar histological patterns , and they more commonly affecting women . rarely , patients may present with or subsequently develop both ga and nl [ 2,3,9,1318 ] . to our knowledge , there are ten previously documented cases of ga and nl occurring in the same patient [ 2,3,9,1318 ] . we report on a 67-year - old caucasian female with a history of nl on the lower legs who presented with erythematous papules and plaques over her breasts , trunk , and wrists ; subsequent biopsy of a lesion on the trunk was consistent with ga . we describe the characteristics of patients with concomitant ga and nl and discuss similarities and differences between the two dermatoses . a 67-year - old caucasian woman with a past medical history of diabetes mellitus type 2 and hypertension presented to clinic with a 15-year history of a progressively enlarging , asymptomatic plaques on her lower shins . the patient states the lesions initially began as red bumps that spread out and enlarged . she was seen by an outside dermatologist who had biopsied the area and was told she had necrobiosis lipoidica diabeticorum . physical examination demonstrated erythematous annular plaques with an erythematous rim and atrophic center with yellow discoloration over the lower extremities bilaterally ( figure 1 ) . the patient was seen for follow - up and stated she began developing new lesions on her thighs , trunk upper arm , and wrists ( figure 2a , b , c , d ) . punch biopsy of the chest was performed and revealed discrete areas of palisading histiocytes surrounding collections of mucin with perivascular lymphocytes , suggestive of interstitial granuloma annulare ( figure 3a , b , c ) . granuloma annulare is characterized by grouped papules coalescing into annular plaques occurring most commonly on the back of hands and feet . nl typically presents with erythematous papules and plaques that expand centrifugally and tend to occur on the lower extremities . a pubmed search was performed to find cases of ga and nl occurring in the same patient . the keywords concomitant , granuloma annulare , necrobiosis lipoidica , patient , same , sequential , and simultaneous were used . to the best of our knowledge , there have been 10 reported cases with ga and nl occurring in the same patient . these patients as well as our patient are described ( table 1 ) [ 2,3,9,1318 ] . nine of the 11 patients were women ( 82% ) with an average age of 30 years at the time of having both ga and nl . men ( 2 of the 11 patients , 18% ) were of an average age of 25 years when concomitant ga and nl was discovered . the lesions of ga were found on the ankles , feet , legs , trunk , and upper extremities . of the 11 patients , 7 patients ( 7 of the 11 , 64% ) had diabetes or were pre - diabetic [ 2,3,9,1318 ] . histologic examination of both ga and nl can demonstrate central areas of necrobiosis with an infiltrate of histiocytes and lymphocytes . granuloma annulare has increased mucin in the centers of the granulomas , while nl shows increased extracellular lipids . ga has been associated with hiv and paraneoplastic syndromes while nl does not share these associations [ 2022 ] . in 1934 , ketron suggested that nl might be a variant of ga based on histologic findings . in a publication in 1941 , francis ellis suggested that the lesions of ga and nl could be the same entity . ellis mentions the first patient with both ga and nl in a manuscript by wood and beerman . in 1968 , the topic was readdressed by fred feldman , who presented the first case report primarily focusing on ga and nl in the same patient . in this paper , paul hirsch mentions the presence of ga and nl in the same patient could possibly yield credence to a unifocal pathogenesis . treatment of ga and nl can include intralesional triamcinolone , short courses of systemic steroids , and topical steroids . other therapies used for ga have included dapsone , imiquimod , topical nitrogen mustard , topical retinoids , and ultraviolet light . our patient s nl lesions were treated with intralesional kenalog with improvement ; anecdotally , the patient reports her nl had significant improvement after she began a diet and exercise regimen and subsequently lost 15 pounds . intralesional kenalog , pentoxifylline , and plaquenil have been utilized in the treatment of the patient s ga lesions without benefit . the two diseases share some common characteristics , which may suggest these dermatoses could occur as a spectrum in some patients . we report the eleventh example of a patient with both ga and nl and describe the characteristics of patients with concomitant ga and nl . further studies and evaluation needs to be performed to further elucidate the mechanisms and to discover if these disease entities are related .
granuloma annulare ( ga ) and necrobiosis lipoidica ( nl ) are granulomatous diseases of undetermined etiology . 
 rarely , both dermatoses have been reported to occur concomitantly in patients . 
 ga and nl are characterized histologically by areas of necrobiosis of collagen . 
 the two diseases share some common characteristics , which may suggest that these dermatoses could occur as a spectrum in some patients or possibly share a similar pathogenesis . 
 we report on a 67-year - old caucasian woman with a history of nl on the anterior shins that later developed lesions of ga on the breasts , trunk , and wrist . 
 we also review the literature and discuss the characteristics of patients with concomitant ga and nl .