{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T21:01:40Z","timestamp":1791838900748,"version":"4.3.4"},"reference-count":37,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,3,21]],"date-time":"2023-03-21T00:00:00Z","timestamp":1679356800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pediatr."],"abstract":"<jats:sec><jats:title>Objectives<\/jats:title><jats:p>Subcutaneous granuloma annulare (SGA) is a rare, self-limiting granulomatous disease in children, commonly diagnosed by histopathology following biopsy or surgical excision. This study aimed to identify imaging clues for SGA that could expedite accurate diagnosis and avoid the need for biopsy in children.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We retrospectively analyzed complete hospital records of all children diagnosed with SGA at our institution from January 2001 to December 2020. Detailed disease history, imaging findings, management, and outcome were evaluated.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We identified 28 patients (20 girls) at a median age of 3.75 (range 1\u201312.5 years). Ten patients presented with multiple lesions. Most lesions were located on the lower extremities (<jats:italic>n<\/jats:italic>\u2009=\u200926\/41). Ultrasound examinations were performed on all patients, and 12 (43%) patients also received an MRI. Surgical intervention was conducted in 18 (64%) patients either by incisional biopsy (<jats:italic>n<\/jats:italic>\u2009=\u20096) or total excision of the lump (<jats:italic>n<\/jats:italic>\u2009=\u200912). In all patients who did not undergo surgery, SGA resolved spontaneously. A careful review of the MRIs led to the discovery of a characteristic imaging shape of SGA lesions: the epifascial cap with a typical broad circular base laying on the fascia, extending towards the subdermal\/dermal tissue. This distinctive shape was evident in every patient in our cohort.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>The \u201cEpifascial Cap Sign\u201d is a specific imaging sign for SGA, which to the best of our knowledge, helps distinguish this disease from other subcutaneous lesions. Recognition of this novel diagnostic sign combined with the historical and physical findings should enable clinicians to establish SGA diagnosis easily and diminish the need for further invasive diagnostic procedures.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fped.2023.1069428","type":"journal-article","created":{"date-parts":[[2023,3,21]],"date-time":"2023-03-21T06:12:37Z","timestamp":1679379157000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["The epifascial cap: A typical imaging sign for subcutaneous granuloma annulare in children"],"prefix":"10.3389","volume":"11","author":[{"given":"Besiana P.","family":"Beqo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian","family":"Tschauner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paolo","family":"Gasparella","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iva","family":"Brcic","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emir Q.","family":"Haxhija","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2023,3,21]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"315","DOI":"10.1016\/j.det.2015.03.001","article-title":"Granuloma annulare","volume":"33","author":"Keimig","year":"2015","journal-title":"Dermatol Clin"},{"key":"B2","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1016\/j.jaad.2015.03.054","article-title":"Granuloma annulare: clinical and histologic variants, epidemiology, and genetics","volume":"75","author":"Piette","year":"2016","journal-title":"J Am Acad Dermatol"},{"key":"B3","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1007\/s40257-013-0029-5","article-title":"Etiology, diagnosis, and therapeutic management of granuloma annulare: an update","volume":"14","author":"Thornsberry","year":"2013","journal-title":"Am J Clin Dermatol"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1007\/s40257-021-00636-1","article-title":"Granuloma annulare: an updated review of epidemiology, pathogenesis, and treatment options","author":"Joshi","year":"","journal-title":"Am J Clin Dermatol"},{"key":"B5","first-page":"663","article-title":"Childhood granuloma annulare: a review","volume":"149","author":"Patrizi","year":"2014","journal-title":"G Ital Dermatol Venereol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"867","DOI":"10.1007\/s00105-015-3704-z","article-title":"Granuloma anulare","volume":"66","author":"Butsch","year":"2015","journal-title":"Der Hautarzt"},{"key":"B7","doi-asserted-by":"publisher","first-page":"96","DOI":"10.1016\/j.sder.2007.02.006","article-title":"Subcutaneous granuloma annulare","volume":"26","author":"Requena","year":"2007","journal-title":"Semin Cutan Med Surg"},{"key":"B8","doi-asserted-by":"publisher","first-page":"677","DOI":"10.1111\/1346-8138.15352","article-title":"Subcutaneous granuloma annulare on the heel: a case report and review of the Japanese published work","volume":"47","author":"Endo","year":"2020","journal-title":"J Dermatol"},{"key":"B9","doi-asserted-by":"publisher","first-page":"845","DOI":"10.1148\/radiology.210.3.r99mr11845","article-title":"Subcutaneous granuloma annulare: MR imaging features in six children and literature review","volume":"210","author":"Chung","year":"1999","journal-title":"Radiology"},{"key":"B10","doi-asserted-by":"publisher","first-page":"395","DOI":"10.2214\/ajr.164.2.7839977","article-title":"Benign soft-tissue tumors in a large referral population: distribution of specific diagnoses by age, sex, and location","volume":"164","author":"Kransdorf","year":"1995","journal-title":"AJR Am J Roentgenol"},{"key":"B11","doi-asserted-by":"publisher","first-page":"e30","DOI":"10.1097\/PEC.0000000000000591","article-title":"Subcutaneous granuloma annulare: a diagnostic conundrum-learning from mistakes","volume":"33","author":"Pederiva","year":"2017","journal-title":"Pediatr Emerg Care"},{"key":"B12","doi-asserted-by":"publisher","first-page":"e200","DOI":"10.1111\/pde.13470","article-title":"Usefulness of ultrasonography in the diagnosis of subcutaneous granuloma annulare","volume":"35","author":"V\u00e1zquez-Osorio","year":"2018","journal-title":"Pediatr Dermatol"},{"key":"B13","first-page":"19","article-title":"Subcutaneous granuloma annulare of the scalp in childhood: a case report and review of the literature","volume":"17","author":"Sabuncuo\u011flu","year":"2007","journal-title":"Turk Neurosurg"},{"key":"B14","doi-asserted-by":"publisher","first-page":"887","DOI":"10.1148\/rg.293085168","article-title":"Pediatric soft-tissue tumors and pseudo-tumors: MR imaging features with pathologic correlation: part 1. 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