Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2023;13(4):e2023207 1 Papular Granuloma Annulare Mimicking Viral Warts Carlotta Gurioli1,2, Cosimo Misciali1,2, Silvia Robuffo1,2, Carlotta Baraldi1,2, Lindsay Brooke Boling3, Bianca Maria Piraccini1,2 1 Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy 2 Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy 3 Allergy and Clinical Immunology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy Citation: Gurioli C, Misciali C, Robuffo S, Baraldi C, Boling LB, Piraccini BM. Papular Granuloma Annulare Mimicking Viral Warts. Dermatol Pract Concept. 2023;13(4):e2023207. DOI: https://doi.org/10.5826/dpc.1304a207 Accepted: March 19, 2023; Published: October 2023 Copyright: ©2023 Gurioli 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: Silvia Robuffo, IRCCS Azienda Ospedaliero-Universitaria di Bologna; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy; Via Massarenti 1, 40138 Bologna, Italy. Telephone number +390512144838 E-mail: silvia.robuffo@studio.unibo.it Case Presentation We report the case of a 29-year-old Caucasian male that presented to our clinic with a four-year history of having several small, shiny flesh-colored/erythematous papular le- sions confined to the dorsal surfaces of his fingers and hands bilaterally (Figure 1, A and B). There were no systemic symp- toms, no smoking habit reported, and no history of diabetes mellitus or other chronic diseases. At the time of the visit, a dermoscopic examination of the lesions was carried out that showed circular areas of varied dotted and linear irregular vessels on a pink to white background (Figure 1C). A punch biopsy was performed for histological examination. The histopathology was compatible with granuloma annulare (GA) of the hands, showing an area of palisading histiocytes around both degeneration of collagen and mucin deposition (Figure 1D). Blood work (including a complete blood count, plasma glucose levels, liver and renal function tests, and au- toimmunity screening) were performed and resulted within the normal limits [1]. After evaluating the different thera- peutic options that exist for GA, a 4-week treatment with a potent topical steroid ointment was prescribed [2]. 2 Image Letter | Dermatol Pract Concept. 2023;13(4):e2023207 Teaching Point GA is the most common non-infectious cutaneous granulo- matous disease and can manifest with many clinical variants, sometimes mimicking other conditions such as viral warts. Considering the frequency with which dermatologists see vi- ral warts, differential diagnoses and biopsy often may not be considered. This case highlights the crucial importance of clinical and histopathological correlation for a definitive di- agnosis, leading to an improved management of these inflam- matory lesions and, above all, their atypical clinical variants. References 1. Barbieri JS, Rosenbach M, Rodriguez O, Margolis DJ. As- sociation of Granuloma Annulare With Type 2 Diabetes, Hyperlipidemia, Autoimmune Disorders, and Hematologic Ma- lignant Neoplasms.  JAMA Dermatol.  2021;157(7):817–823. DOI:10.1001/jamadermatol.2021.1805. PMID: 34106218; PMCID: PMC8190702. 2. Wang J, Khachemoune A. Granuloma Annulare: A Focused Re- view of Therapeutic Options. Am J Clin Dermatol. 2018(3): 333-344. DOI: 10.1007/s40257-017-0334-5. PMID: 29230666. Figure 1. Papular granuloma annulare. (A, B) Morphology of cutaneous lesions on the dorsal aspects of the hands; (C) Dermoscopic exam- ination displays varied irregular linear and dotted vessels over a pink to whitish background and (D) Cutaneous biopsy findings showing an area of palisading histiocytes, degenerated collagen bundles, and mucin deposition (H&E, original magnification ×20).