Granuloma annulare | Test Guess and Go

Today is the 9th day of my 3-week gluten-free (GF) trial. Last Monday’s post outlined my reasons for this experiment and discussed my doubt that this diet will make any difference in my health status.

Has it been hard to do?: So far the diet has been easy to follow. Because I have been eating low-carb for quite a while, bread has had a small role in my life: just an occasional piece of peanut butter toast. Cereal has been completely banned except for an infrequent handful of Honey Nut Cheerios for a needed junk food fix. I haven’t bought crackers in months except for six-packs of Ritz peanut butter crackers. Ice cream is our usual household fix for sweet and chocolate.

The food plan that I’ve followed in the last 9 days has been a non-cheating version of my normal diet. I believe that if I’m going to bother giving GF a try, then I must stay completely GF for the 21 days. A trial with cheating or even one cracker becomes invalid and means that I’ve wasted my time.

Any goofs?: The closest that I have come to eating a wheat product came when I was fixing lunch for my 1-year old granddaughter on Wednesday. As every parent/grandparent knows, it is easy to nibble when fixing meals for children. I was putting small pasta shells on her tray and twice caught myself grabbing one for a taste. What a bummer it would have been to accidentally go off the diet with mindless eating.

Blood sugar effects?: There was nothing about this change in diet that noticeably affected my blood sugar. I had many good days and a few mornings with unexpected highs. As always, the problems were related to activity levels more than diet. I walk the dog for 45-60 minutes almost every morning. This moderate but sustained activity works miracles in preventing post-breakfast spikes. One would think that the hour and a half I spent bailing water out of the sump on Thursday morning (the pump couldn’t keep up with our massive rainfall) would have had kept my blood sugar in range. But my reward was a dry basement accompanied by highs approaching 200. On Friday morning the grandchildren were with me and made a long walk impossible. I increased my insulin but obviously not enough to tame my BG. Nighttime blood glucose levels were much better than normal all week because of minimal snacking after dinner.

Do I feel different?: After 9 days I feel the same and there has been no change in my granuloma annulare. It would be naive to expect anything different. I didn’t do this trial because of digestive problems or feelings of illness or fatigue and those are the things that sometimes see immediate improvement. Granuloma annulare tends to be a constantly morphing condition with no rhyme nor reason. If diet were to have an impact, I would expect it to be a change that would be many months in the making. Even then it would be difficult to prove that diet was responsible for any improvement.

Any special foods?: The only special GF product that I purchased is a loaf of bread from Trader Joe’s. Right out of the package it is totally rude. Toasted with peanut butter it is okay. One piece of bread is approximately the same carb count as my usual bread, but it is half the size (very small). Although I understand the arguments for avoiding wheat, I look at the list of ingredients in this Rye-less “Rye” and am askance at the leading ingredients of water, tapioca flour, white rice flour, and rice starch. IMO these are neither nutritious nor blood sugar-friendly foods.

What now?: I am committed to finishing my gluten-free experiment. Because it is not a substantial change to my diet, I believe that the only way this diet can help me is if I have a wheat sensitivity. I don’t think that I do. Because I am eating a lot of fruit and vegetables and not a lot of processed food, this should be great for my diabetes and maybe help me lose a pound or two.

Summary: Unlike people who hope to see improvements in their health from a gluten-free lifestyle, I don’t want to deal with this diet for the rest of my life. I’m actually keeping my fingers crossed that I see no benefits. But what if it does help my granuloma annulare? Less unsightly skin versus pizza? Interesting choice. I guess I would have to learn to make cauliflower crust pizza. Then I would have to look in the mirror and seriously weigh the benefits of a life without pizza at Costco.

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.”

No Photos Allowed 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.