presence of a central lumen, chronic discharge, or failure to respond to traditional treatment should prompt the clinician to consider these rare umbilical anomalies The distinction is of great clinical significance because these problems may be associated with other congenital malformations, and surgical excision of the entire remnant is necessary to prevent sequelae, such as infection Diagnosis is most commonly made by ultrasound FIGURE 120.18 Large pedunculated umbilical granuloma that responded to suture ligation and repeated silver nitrate applications Granuloma Annulare The lesions of granuloma annulare are composed of infiltrates of lymphocytes and altered collagen within the dermis They appear first as raised nodules that gradually expand centrifugally to form annular rings with central clearing ranging from to cm in diameter They have a firm, fibrous, sometimes-lumpy consistency on palpation Overlying skin can range from normal, to erythematous, violaceous, or slightly hyperpigmented ( Fig 120.19 ) Although most are asymptomatic, patients occasionally report mild pruritus and present with superficial excoriation caused by scratching The lack of an active microvesicular border, firm consistency on palpation, deeper dermal location, and failure to respond to antifungals help distinguish these lesions from tinea corporis Lesions are commonly found on the extensor surfaces of the lower portions of legs and the dorsum of the hands and feet and, less often, on the trunk or abdominal wall Although granuloma annulare may present at any age, more than 40% of cases appear after infancy and before 15 years of age Because most lesions resolve within to years, reassurance is usually all that is necessary