10.5826/dpc.1302a173
text/xml
2160-9381
3382
en
Surabhi  Dayal
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Author’s Reply to Letter to the Editor “Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase”
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2023-04-29
2023-03-30
2023-04-29
2023-06-05
e2023173
Dermatol Pract Concept
Surabhi  Dayal
2023/04/29
10.5826/dpc.1302a173
e2023173
Department of Dermatology, Venereology and Leprology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India 
2160-9381
en
e2023173
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.
Author’s Reply to Letter to the Editor “Subcutaneous Granuloma Annulare in an Atypical Age Group in Immediate Post-Covid-19 Phase”
https://dpcj.org/index.php/dpc/article/download/3382/2111
       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,                                                             SGA in the article cited by the commenters themselves and
                                                                         previously observed in other studies too[4,5].
We appreciate the commenter’s interest shown for our                          Regarding the issue raised on mobility of nodules re-
­article [1]. We agree that generalized granuloma a­ nnulare             ported in our case, we would like to bring reader’s attention
(GGA) affects at least the trunk and either upper and/                   to the study on 47 pediatric SGA cases [5]. Among 53 total
or lower extremities as first described by Dabski and                    subcutaneous nodules, 25 were in fact freely mobile, while
­Winkelmann who studied 100 cases of GGA. However, it is                 23 were not or slightly mobile. Immobility or fixity occurs
important to note that the lesional morphology was either                more commonly when SGA extends and attaches to under-
annular plaques in ring-like configuration or non-annular                lying periosteum as in the cases of lesions over scalp and
papules in their study [2]. GGA clinically presents as wide-             forehead [5].
spread macules or papules or annular plaques on the trunk                     Interpreting our case as GGA rather than SGA may have
and limbs unlike our case which had a single type of clinical            been caused by the erythematous lesion pointed with red ar-
morphology of painless subcutaneous nodules [3,4].                       row labelled as ‘biopsy site’ instead of ‘attempted biopsy site’
    Subcutaneous granuloma annulare (SGA) usually pres-                  (indicating post-surgical wound after suture removal), which
ents as skin-colored subcutaneous nodules with minimal to                might be misinterpreted as an annular plaque of GGA.
absent cutaneous surface changes. A slight erythema in very                   SGA is usually an authentic and exclusive panniculitic
few lesions (3 out of 23 nodules) in our case was seen, similar          process with no dermal involvement, however, 25% cases
to the faint erythema noticeable in the clinical photograph of           may have coexistent findings of granuloma annulare in the




Letter to the Editor | Dermatol Pract Concept. 2023;13(2):e2023173                                                                     1
dermis [6]. Histopathologically, SGA should have areas of          References
basophilic degeneration of collagen bundles with peripheral
palisading granulomas involving connective tissue septae           1. Kaur L, Chakraborty D, Dayal S, Singh S, Yadav K.
                                                                      Subcutaneous Granuloma Annulare in an Atypical Age
                                                                      ­
of the subcutis [6]. The histopathology in our case revealed
                                                                      Group in Immediate Post-Covid-19 Phase. Dermatol Pract
necrobiotic granulomas exclusively involving subcutane-
                                                                      ­Concept. 2022;12(4):e2022156. DOI: 10.5826/dpc.1204a156.
ous septae while in GGA upper and middle dermis shows                  PMID: 36534560. PMCID: PMC9681236.
predominant participation [6]. As our case presented very          2. Dabski K, Winkelmann RK. Generalized granuloma annulare:
early, within 7 days from onset, the biopsied nodule might             clinical and laboratory findings in 100 patients. J Am Acad Derma-
be purely subcutaneous without upper dermal participation              tol. 1989;20(1):39-47. DOI:10.1016/s0190-9622(89)70005-0.
                                                                       PMID: 2913080.
yet, causing relatively smaller granulomas on histopathology.
                                                                   3. Bourke J. Granulomatous disorders of the skin. In: Griffiths
    Although imaging alone may be preferred in children be-
                                                                       CEM, Barker J, Bleiker T, Chalmers R, Creamer D, ed. Rook’s
ing non-invasive, its utility as substitute for biopsy in adults       Textbook of Dermatology. 9th ed. UK: John Wiley & Sons;
needs to be confirmed with further imaging studies in adult            2016:97.1-7.
SGA. We emphasize that SGA does not occur exclusively in           4. Piette EW, Rosenbach M. Granuloma annulare: Clinical and
children but can be observed in adults as well, although it is         histologic variants, epidemiology, and genetics. J Am Acad Der-
                                                                       matol. 2016;75(3):457-465. DOI:10.1016/j.jaad.2015.03.054.
rare and may follow a different disease course in comparison
                                                                       PMID: 27543209.
to the children one.
                                                                   5. Felner EI, Steinberg JB, Weinberg AG. Subcutaneous granuloma
    Further contemplating, our case might fit into a general-          annulare: a review of 47 cases. Pediatrics. 1997;100(6):965-967.
ized form of SGA, as generalized form of perforating GA [3].           DOI:10.1542/peds.100.6.965. PMID: 9374565.
In conclusions, since the primary and the only lesions in our      6. Requena L. Panniculitis. In: Griffiths CEM, Barker J, Bleiker T,
case were subcutaneous nodules, the term GGA as diagnosis              Chalmers R, Creamer D, ed. Rook’s Textbook of Dermatology.
                                                                       9th ed. UK: John Wiley & Sons; 2016:99.13-14.
of our case should be discouraged.




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