CPD • A memorable patient CED Clinical and Experimental Dermatology CPD Malignancy-associated generalized perforating granuloma annulare R. Satta, 1 G. Biondi, 1 G. M. Puggioni, 1 M. A. Montesu 1 and F. Rongioletti 2 1 Department of Surgical, Microsurgical and Medical Sciences, Unit of Dermatology, University of Sassari, Sassari, Italy; and 2 Department of Medical Sciences – Unit of Dermatology, University of Cagliari, Cagliari, Italy doi: 10.1111/ced.13373 Granuloma annulare (GA) is a benign, granulomatous disease with several variants, including localized, gen- eralized, subcutaneous, patch, papular, linear and per- forating forms. The generalized variant of GA os associated with diabetes mellitus, hyperlipidaemia, autoimmune thyroiditis, and rarely with human immunodeficiency virus (HIV) infection, solid tumours and lymphomas. Perforating GA (PGA), first described by Owens and Freeman in 1971, 1 constitutes only 5% of all forms of GA. Although PGA has been sporadi- cally described in association with diabetes mellitus, tuberculosis, rheumatoid arthritis, HIV/acquired immunodeficiency syndrome and herpes zoster infec- tion, 2,3 there is no report of a paraneoplastic link between PGA and malignancies. We present a case of malignancy-associated PGA ‘generalized type’ as the first manifestation of multiple myeloma. A 70-year-old man presented with an itchy papular eruption spreading all over his body. His medical history included monoclonal gammopathy of un- determined significance (MGUS), diagnosed 3 years previously. On physical examination, multiple, isolated, pinkish, umbilicated papules 5 mm in diameter were seen on the patient’s body, localized to the trunk, limbs, flexu- ral areas, hands and feet, and sparing the head and face (Fig. 1a,b). Some papules were surmounted by a yellowish scaly crust, producing a pseudopustular appearance. Histopathology of a skin lesion showed a granulo- matous infiltrate composed of lymphocytes, histiocytes Correspondence: Dr Rosanna Satta, Department of Surgical, Microsurgical and Medical Sciences, Unit of Dermatology, University of Sassari, V. le S Pietro 43, 07100 Sassari, Italy E-mail: rsatta@uniss.it Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 31 January 2017 (b) (a) Figure 1 (a) Multiple pinkish umbilicated papules on the limbs. (b) In some areas the papules created an annular configuration with central sparing. Some annular papules were surmounted by a yellowish scaly crust, giving a pseudopustular appearance. Figure 2 Superficial granulomas attached to the epidermis with transepidermal discharge of material (haematoxylin and eosin, original magnification 9 10). ª 2018 British Association of Dermatologists Clinical and Experimental Dermatology 1 CPD