Dermatology: Practical and Conceptual Letter to the Editor | Dermatol Pract Concept. 2023;13(2):e2023173 1 Author’s Reply to Letter to the Editor “Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase” Lovleen Kaur1, Surabhi Dayal1 1 Department of Dermatology, Venereology and Leprology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India Citation: Kaur L, Dayal S. Author’s Reply to Letter to the Editor “Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase”. Dermatol Pract Concept. 2023;13(2):e2023173. DOI: https://doi.org/10.5826/dpc.1302a173 Accepted: March 30, 2023; Published: April 2023 Copyright: ©2023 Kaur 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: Lovleen Kaur, MD, Department of Dermatology, Venereology and Leprology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India; Contact: +917888661584; E-mail: dr.lovleen555@gmail.com Dear Editor, We appreciate the commenter’s interest shown for our article  [1]. We agree that generalized granuloma annulare (GGA) affects at least the trunk and either upper and/ or lower extremities as first described by Dabski and Winkelmann who studied 100 cases of GGA. However, it is important to note that the lesional morphology was either annular plaques in ring-like configuration or non-annular papules in their study [2]. GGA clinically presents as wide- spread macules or papules or annular plaques on the trunk and limbs unlike our case which had a single type of clinical morphology of painless subcutaneous nodules [3,4]. Subcutaneous granuloma annulare (SGA) usually pres- ents as skin-colored subcutaneous nodules with minimal to absent cutaneous surface changes. A slight erythema in very few lesions (3 out of 23 nodules) in our case was seen, similar to the faint erythema noticeable in the clinical photograph of SGA in the article cited by the commenters themselves and previously observed in other studies too[4,5]. Regarding the issue raised on mobility of nodules re- ported in our case, we would like to bring reader’s attention to the study on 47 pediatric SGA cases [5]. Among 53 total subcutaneous nodules, 25 were in fact freely mobile, while 23 were not or slightly mobile. Immobility or fixity occurs more commonly when SGA extends and attaches to under- lying periosteum as in the cases of lesions over scalp and forehead [5]. Interpreting our case as GGA rather than SGA may have been caused by the erythematous lesion pointed with red ar- row labelled as ‘biopsy site’ instead of ‘attempted biopsy site’ (indicating post-surgical wound after suture removal), which might be misinterpreted as an annular plaque of GGA. SGA is usually an authentic and exclusive panniculitic process with no dermal involvement, however, 25% cases may have coexistent findings of granuloma annulare in the 2 Letter to the Editor | Dermatol Pract Concept. 2023;13(2):e2023173 dermis [6]. Histopathologically, SGA should have areas of basophilic degeneration of collagen bundles with peripheral palisading granulomas involving connective tissue septae of the subcutis [6]. The histopathology in our case revealed necrobiotic granulomas exclusively involving subcutane- ous septae while in GGA upper and middle dermis shows predominant participation [6]. As our case presented very early, within 7 days from onset, the biopsied nodule might be purely subcutaneous without upper dermal participation yet, causing relatively smaller granulomas on histopathology. Although imaging alone may be preferred in children be- ing non-invasive, its utility as substitute for biopsy in adults needs to be confirmed with further imaging studies in adult SGA. We emphasize that SGA does not occur exclusively in children but can be observed in adults as well, although it is rare and may follow a different disease course in comparison to the children one. Further contemplating, our case might fit into a general- ized form of SGA, as generalized form of perforating GA [3]. In conclusions, since the primary and the only lesions in our case were subcutaneous nodules, the term GGA as diagnosis of our case should be discouraged. References 1. Kaur L, Chakraborty D, Dayal S, Singh S, Yadav K. Subcutaneous 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. Dabski K, Winkelmann RK. Generalized granuloma annulare: clinical and laboratory findings in 100 patients. J Am Acad Derma- tol. 1989;20(1):39-47. DOI:10.1016/s0190-9622(89)70005-0. PMID: 2913080. 3. Bourke J. Granulomatous disorders of the skin. In: Griffiths CEM, Barker J, Bleiker T, Chalmers R, Creamer D, ed. Rook’s Textbook of Dermatology. 9th ed. UK: John Wiley & Sons; 2016:97.1-7. 4. Piette EW, Rosenbach M. Granuloma annulare: Clinical and histologic variants, epidemiology, and genetics. J Am Acad Der- matol. 2016;75(3):457-465. DOI:10.1016/j.jaad.2015.03.054. PMID: 27543209. 5. Felner EI, Steinberg JB, Weinberg AG. Subcutaneous granuloma annulare: a review of 47 cases. Pediatrics. 1997;100(6):965-967. DOI:10.1542/peds.100.6.965. PMID: 9374565. 6. Requena L. Panniculitis. In: Griffiths CEM, Barker J, Bleiker T, Chalmers R, Creamer D, ed. Rook’s Textbook of Dermatology. 9th ed. UK: John Wiley & Sons; 2016:99.13-14.