Two children had generalized perforating granuloma annulare. In both patients, the disease began at the age of 3 and persisted for three years. The majority of lesions were on the extremities, and a definite seasonal influence was present with exacerbation during the summer and almost complete clearing during the winter. Moderate pruritus was present in one child. The lesions begin as flesh-colored papules that become slightly inflammatory, develop a central crust (the perforation), and then slowly resolve. Careful histologic examination is necessary to find the perforation; however, the typical histologic picture of granuloma annulare can be found without difficulty.
Duncan WC, Smith JD, Knox JM. Generalized Perforating Granuloma Annulare. Arch Dermatol. 1973;108(4):570-572. doi:10.1001/archderm.1973.01620250054020