I’ve got a secret list. A list that I won’t share even if I knock on wood with Woody Woodpecker-like fervor. A list that the mere mention of the Top Ten (or is it the Bottom Ten?) would jinx me for sure. If you’ve got diabetes, you probably have a list like this. It’s the list of diabetes complications that you don’t want to get. It’s a list with negotiated rankings. I could deal with this as long as that doesn’t happen to me. I know that this might be inevitable, but I’ll be okay as long as I don’t have to live with that. I know I’m brave, but please, please, please never test my courage with <fill in the blank>.
Some of the complications on this list are life-threatening. Other things are merely cosmetic or at worst a minor irritation. Some line items are thought to be the result of too many high blood sugars (let’s add a boatload of guilt here!) while others are related to autoimmunity, duration of diabetes, and age. Some of these complications share the clubhouse with diabetes and doctors aren’t sure why. My list is always changing because things that I have never heard of keep jumping into my medical chart.
My most frustrating health issue right now is a skin problem called disseminated granuloma annulare (GA). It doesn’t hurt; it doesn’t itch; it is ugly, ugly, ugly. The most common form of GA is localized with a small number of clustered nodules usually on the hands, feet, knees or elbows. These clusters often disappear in a year or two with no treatment. Disseminated (or generalized) annulare granuloma is an out-of-control inflammatory condition that can tattoo your whole body with a variety of nodules, red patches, and unsightly blemishes. It can last for ten or more years.
Two and a half years ago I had a bunch of bumps on my elbows. Thinking that they might be the beginning of psoriasis, my rheumatologist recommended a dermatology consult. My dermatologist indicated that the bumps were not psoriasis (yeah!). She believed that they were granuloma annulare and took a biopsy to confirm. I had never heard of this condition and quickly consulted my online physician, Dr. Google.
There is not a lot of information on what causes granuloma annulare. In a 2013 case report by Mariele De Paola et al., it is stated:
The pathogenesis of GA remains still obscure. Possible pathogenetic factors suggested include humoral and delayed type hypersensitivity, vascular damage, metabolic disorder, or primary collagen and/or elastin alteration mediated through an immunologic mechanism.
One study indicates that diabetes is in the picture about 10-15% of the time while another study indicates that there is no statistical correlation between GA and Type 2 diabetes. A 2007 retrospective analysis at the Mayo Clinic found insulin-dependent diabetes in about 10% of the GA cases studied and thyroid disorders in 16%. These statistics at best show a weak link to diabetes, but most researchers still keep it in the equation. A 2006 article about granuloma annulare by Peggy R. Cyr, M.D. reports that there is a stronger link to diabetes in those patients who have the disseminated variant that I have.
The American Diabetes Association positions granuloma annulare at the bottom of its list of skin complications of diabetes. I wish that my experience was as simple as the ADA advises: “See your doctor if you get rashes like this. There are drugs that can help clear up this condition.”
My somewhat localized granuloma annulare exploded last fall. By December it was spreading noticeably from day-to-day and was officially disseminated granuloma annulare. The prescription-strength cortisone cream that helped two years ago was useless. Because this variation of GA is unusual (about 15% of all cases), there are no large clinical trials to guide my dermatologist in choosing an effective treatment. Instead she keeps showing me the “big brown book” with the list of medications that have been helpful for patients in small anecdotal studies of 1 to 10 patients. Many of these drugs overlap with medications for rheumatoid arthritis, psoriasis, and acne and the list includes Dapsone, Accutane, Plaquenil, and Remicade. As Dr. Cyr writes: “The possible benefit of treatment, which is unclear given the lack of clinical trials, must be balanced against the significant toxicities of most of these treatments.”
I am currently taking nicotinamide which is a water-soluble member of the B vitamin group. Nicotinamide rarely causes side effects even at high doses and my dermatologist has prescribed this treatment because of its lack of toxicity. The basis for the use of this product is a 1983 paper by Alice Ma, M.D. discussing the complete clearing of generalized granuloma annulare in one (!) patient after 24 weeks of high doses of nicotinamide. It has also been used successfully for inflammatory acne and that is probably the more likely justification for using it for GA.
Is nicotinamide helping me? Some days I think so. Other days I think not at all. Is GA affected by blood sugar levels? Not in my experience and not according to any articles that I have read. Is GA related to other health issues besides diabetes? Granuloma annulare has been linked to autoimmune thyroid disease, some types of cancer, and HIV infection in addition to diabetes. Is GA autoimmune? No, it’s inflammatory, but inflammation and autoimmunity go hand-in-hand when you have clusters of autoimmune/inflammatory conditions as I do.
One thing that I find interesting is that when I write about my medical issues, I usually link them to Type 1 diabetes. Granuloma annulare actually seems to have a stronger correlation with thyroid disease but typically I have glossed over that. I suppose I do that because I have never been symptomatic for hypothyroidism and the little pill I take every morning is an inconsequential part of my life. On the other hand, diabetes always demands attention and is woven into almost every minute of every day.
An important issue is what granuloma annulare is doing to my psyche. One good thing is that GA rarely shows up on the face. Therefore I can live the rest of my life in turtlenecks and long pants. A great solution for cool weather but not so great for summertime…. The hardest part is that I can follow my doctor’s orders and still have no control over the unsightly lesions. When you have Type 1 diabetes, you get used to the idea that WHAT I DO MAKES A DIFFERENCE in my health. GA abuses that notion daily. I have to admit that I am getting used to dealing with it and I try to remind myself that it’s not itchy, painful, or life-threatening.
Growing older with a cascading series of autoimmune/inflammatory issues requires an acceptance of today without worrying about tomorrow. My secret list of diabetes complications will always be in my back pocket, but being afraid of it accomplishes nothing. Granuloma annulare is a frustrating skin condition and I hope that it eventually goes away. But there is no reason to let it ruin today or tomorrow. It is what it is and nothing more.