Apremilast in the Management of Generalized Granuloma Annulare: A Case Series

Background: Granuloma annulare is a difficult disease to treat and can lead to anxiety and frustration for both patients and providers. The pathogenesis of granuloma annulare is unknown, resulting in few thoroughly studied or consistently effective treatments. Objective: 1) To discuss whether treatment with apremilast could lead to improvement or resolution of generalized granuloma annulare. 2) To explore the possible pathogenesis of granuloma annulare and the mechanism of apremilast in treating this disease. Methods: A case series was used to study the clinical response of 6 patients with a history of recalcitrant generalized granuloma annulare taking apremilast 30mg twice daily. Results: Two patients achieved complete clearance of their disease without recurrence while the remaining 4 patients achieved significant improvement in lesion number, induration, and erythema. Limitations: This is a small case series and larger, controlled trials with long-term follow-up are needed. There is no objective method for evaluating the extent of disease improvement in granuloma annulare. Furthermore, our patients used concomitant topical and intralesional steroids while on apremilast. Conclusion: This case series illustrates a novel therapy, apremilast, a phosphodiesterase-4 inhibitor, in the treatment of patients with generalized granuloma annulare and explores possible mechanisms behind the success of this treatment.