A 45-year-old patient was treated for diffuse granuloma annulare with a small molecule drug that affects the immune system

Granulomas due to immune disorders

Ho Chi Minh City Anh Chinh, 45 years old, had granuloma annulare for more than 10 years, now being treated with small molecule drugs that affect the immune mechanism, improving the damage after 4 months.

Dr. BS.CKII Dang Thi Ngoc Bich, Head of Dermatology - Skin Aesthetics, Tam Anh General Hospital, Ho Chi Minh City, said granuloma annulare is a skin disease caused by a long-term immune disorder, causing lesions to continuously form. In people with the disease, due to an unknown cause, the immune system continuously sends out alarm signals even though there is no longer an agent to fight against. Immune cells, especially T lymphocytes and macrophages, continue to concentrate in the skin, creating persistent inflammatory foci and forming granulomatous lesions.

According to Dr. Bich, in the past, granuloma annulare, especially the diffuse form, was mainly treated with topical anti-inflammatory drugs or systemic immunosuppressive drugs. Because systemic medications have many side effects, topical medications are often preferred, but they mainly control skin damage, so the disease can easily prolong, recur, or become resistant to treatment. Currently, small molecule drugs directly affect the immune mechanism that causes disease, opening up a way to control diffuse, persistent or treatment-resistant granuloma annulare.

Like Mr. Chinh, after more than 10 years of treatment at many hospitals from North to South, changing many types of topical medications, the disease still did not cure. Initially, he only had a few small lesions in the neck area, was diagnosed with atopic dermatitis and treated with topical medication. Tổn thương có lúc giảm nhưng sau đó lan lên mặt, xuống hai tay và nhiều vị trí khác trên cơ thể. Các tổn thương cũ chưa hết, tổn thương mới tiếp tục xuất hiện.

When he arrived at Tam Anh General Hospital in Ho Chi Minh City, Dr. Bich diagnosed him with diffuse granuloma annulare - a less common disease than localized granuloma annulare, which tends to last, spread and recur many times. The incidence of this disease is about 0.04-0.06% of the population according to statistics in the US in the period 2017-2018, occurring 3 times more often in women than in men.

Mr. Chinh did not respond to topical anti-inflammatory drugs or local injections, so Dr. Bich decided to change his strategy, switching from controlling each lesion on the skin to directly affecting the immune mechanism causing the disease. The doctor prescribed treatment with small molecule drugs capable of inhibiting the JAK-STAT signaling pathway, one of the links involved in the immune activation process.

Recent studies show that granuloma annulare is an immune-mediated inflammatory disease with the participation of many cytokines such as IFN-γ, TNF-α, IL-15 and IL-21 and the JAK-STAT signaling pathway. Sự hoạt hóa kéo dài khiến hệ miễn dịch luôn trong trạng thái hoạt động, duy trì tình trạng viêm mạn tính. Ở thể lan tỏa, các tổn thương mới liên tục xuất hiện tại nhiều vùng da.

Before starting the new therapy, Mr. Chinh was tested for liver and kidney function, blood lipids as well as screened for potential infections such as tuberculosis, hepatitis B, hepatitis C and HIV, ensuring he was eligible to take the medicine. By regulating inflammatory signals from within, the drug helps lesions gradually improve and limits the formation of new inflammatory foci.

Sau 4 tháng chỉ dùng thuốc uống, anh Chính gần như không xuất hiện thêm các tổn thương mới. The old granuloma patches gradually collapse, the inflammation is clearly reduced and the color of the lesions is lighter, the skin is flat. Để duy trì đáp ứng và hạn chế nguy cơ tái phát, anh cần tiếp tục điều trị 6-12 tháng theo phác đồ.

Bác sĩ Bích lưu ý không phải mọi trường hợp u hạt vòng đều cần điều trị tích cực toàn diện. Nhiều bệnh nhân thể khu trú có thể tự khỏi hoặc chỉ cần điều trị tại chỗ. However, when the disease becomes widespread, persistent or resistant to treatment, the patient should go to the hospital to be examined, because treatment may need to change from simply treating skin lesions to controlling the immune mechanism causing the disease.

Minh Huong

*Patient's name has been changed