Dermatology: Practical and Conceptual Letter to Editor | Dermatol Pract Concept. 2023;13(2):e2023172 1 Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase Besiana P. Beqo1, Emir Q. Haxhija1 1 Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria Citation: Beqo BP, Haxhija EQ. Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase. Dermatol Pract Concept. 2023;13(2):e2023172. DOI: https://doi.org/10.5826/dpc.1302a172 Accepted: March 20, 2023; Published: April 2023 Copyright: ©2023 Beqo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Emir Haxhija MD PhD FEBPS, Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, A-8036 Graz, Austria. Phone: +43-(0)316 – 38513762 Fax: +43-(0)316 – 38513775 Email: emir.haxhija@medunigraz.at Dear Editor, We are writing in response to the article “Subcutaneous Granuloma Annulare in an Atypical Age Group in Immedi- ate Post-Covid-19 Phase” (DOI: https://doi.org/10.5826/ dpc.1204a156) that was recently published in your es- teemed journal [1]. As the topic of subcutaneous granuloma annulare (SGA) is of particular interest to us, we would like to offer  our comments regarding the case presented in the article. Upon review of the clinical and histopathological fea- tures described, we respectfully suggest that the case pre- sented in the article appears to be more compatible with the diagnosis of generalized granuloma annulare (GGA), rather than SGA. GGA is characterized by the presence of 10 or more skin plaques with a circular appearance “affecting at least the trunk and either upper or lower, or both extremities” [2], with smaller or larger subdermal extensions of the granulo- mas beneath these skin lesions, sometimes seen in a patchy pattern [3]. GGA is more common in adults. Although its etiology is still unknown, various triggering mechanisms, including infectious diseases, have been reported [4], which could have been the case in the report presented by Kaur et al. In contrast, SGA is almost exclusively seen in children and presents as immobile, solid, non-tender, non-inflammatory subcutaneous lumps that often appear as single or multiple lesions with rare overlying cutaneous abnormalities. These lumps are asymptomatic and attached to the deep fascia with a clear epifascial extension, and they spontaneously regress without any treatment over a period of 1-2 years [5]. The histopathologic images presented in the report by Kaur et al do not appear to reveal typical SGA histopathology as it is classically seen in children but rather suggest GGA with a patchy pattern of small granulomatous islands. Our recent research has shown that SGA can be recog- nized by the epifascial cap shape of the subcutaneous lesions on ultrasound and MR imaging, which can aid in the accu- rate diagnosis of SGA [5]. This new imaging sign may help avoid unnecessary examinations and specialist consultations for children with SGA and enable accurate diagnosis through imaging alone (Figure 1). Finally, it is worth noting that SGA lumps typically self-resolve in up to 2 years, while lesions described by Kaur 2 Letter to Editor | Dermatol Pract Concept. 2023;13(2):e2023172 et al disappeared within 15 days after intralesional injection of triamcinolone acetonide (10 mg/ml), as commonly ob- served in patients with localized or generalized variants of granuloma annulare. References 1. Kaur L, Chakraborty D, Dayal S, Singh S, Yadav K. Subcu- taneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase. Dermatol Pract Concept. 2022;12(4):e2022156. DOI: 10.5826/dpc.1204a156. PMID: 36534560. PMCID: PMC9681236. 2. Piette EW, Rosenbach M. Granuloma annulare: Clinical and his- tologic variants, epidemiology, and genetics. J Am Acad Dermato.l 2016;75(3):457-465. DOI: 10.1016/j.jaad.2015.03.054. PMID: 27543209. 3. Tsuruta D, Sowa J, Hiroyasu S, Ishii M, Kobayashi H. Con- comitant occurrence of patch granuloma annulare and classical granuloma annulare. J Dermatol. 2011;38:(5):482-485. DOI: 10.1111/j.1346-8138.2010.01070.x. PMID: 21352310. 4. Piette EW, Rosenbach M. Granuloma annulare: Pathogene- sis, disease associations and triggers, and therapeutic options. J Am Acad Dermatol. 2016;75(3):467-479. DOI: 10.1016/j.jaad .2015.03.055. PMID: 27543210. 5. Beqo BP, Gasparella P, Flucher C, Tschauner S, Brcic I, Haxhija EQ. Subcutaneous Granuloma Annulare vs. Subcutaneous Vascular Malformations in Children: A Diagnostic Challenge. Children (Basel). 2023;10(2):362. DOI: 10.3390/children10020362. PMID: 36832491. PMCID: PMC9955411. Figure 1. This composite figure shows a clinical picture of the frontal location of multiple subcutaneous granuloma annulare (SGA) lumps (A). Note the epifascial cap sign in the ultrasound image of two SGA lesions marked with multiple white arrows (B), and in another ultrasound image showing mild peripheral hypervascularization (C). The histopathology of the SGA lesions is characterized by pathogno- monic mucin positive staining of necrobiotic collagen (stars) which is surrounded by inflammatory histiocytes and lymphocytes, ordered in palisades (black arrows).