FIGURE 4.5 Granuloma annulare lesion.

PATIENT POSITION

• Supine on the examination table with the head of the bed elevated 30 degrees.
  
• The patient’s hands are folded in his or her lap.
  
• The clinician stands lateral to or behind the patient, on the same side as the affected area.

ANESTHESIA

• Local anesthesia of the injection site with topical vapocoolant spray.

EQUIPMENT

• 0.5-mL insulin syringe with its attached 8-mm, 31-gauge needle
  
• Steroid solution (10 mg/mL of triamcinolone acetonide)
  
• Gebauer’s Pain Ease mist topical vapocoolant spray
  
• One alcohol prep pad
  
• Sterile gauze pads
  
• Sterile adhesive bandage
  
• Nonsterile, clean chucks pad

TECHNIQUE

1.  Over the lesion, plot out a grid at 1-cm intervals using a ruler and surgical marking pen.

2.  Prep the site with an alcohol pad.

3.  Achieve good local anesthesia by using Gebauer’s Pain Ease mist topical vapocoolant spray (Fig. 4.6).

4.  Position the needle and syringe at a 30-degree angle to the surface of the skin at each injection site.

5.  Using the no-touch technique, quickly introduce the needle into the skin.

6.  Advance the needle to a depth of approximately 2 mm.

7.  Inject 0.01 to 0.05 mL of the steroid solution (10 mg/mL of triamcinolone acetonide) (Fig. 4.7).

8.  Repeat the injections to cover the entire lesion.

9.  Following the injections of the corticosteroid solution, withdraw the needle, and apply direct pressure with the gauze pad.

10.  Apply a sterile adhesive bandage.

11.  The injections may be repeated every 4 to 6 weeks until the lesion resolves (Fig. 4.8).