Aim: To investigate and compare the presentation of granulomatous lesions in optical coherence tomography (OCT) images and compare this to previous studies of nonmelanoma skin tumors. Methods: Two patients with granulomas, tophi and granuloma annulare (GA), respectively, were photographed digitally, OCT-scanned and biopsied in the said order. Normal skin was OCT-scanned for comparison, but not biopsied. The OCT images from each lesion were compared with their histologic images as well as with OCT images with similar characteristics obtained from nonmelanoma skin tumors. Results: The OCT images of the tophi showed hyperreflective, rounded cloud-like structures in dermis, their upper part sharply delineated by a hyporeflective fringe. The deeper areas appeared blurred. The crystalline structures were delineated by a hyporeflective fringe. OCT images of GA showed two different structures in dermis: a hyporeflective rounded one, and one that was lobulated and wing-like. Conclusion: Granulomatous tissue surrounding urate deposits appeared as a clear hyporeflective fringe surrounding a light, hyperreflective area. The urate crystals appeared as hyperreflective areas, shielding the deeper part of dermis, meaning OCT could only visualize the upper part of the lesions. The lobulated, wing-like structure in GA may resemble diffuse GA or a dense lymphocytic infiltrate as seen on histology. The rounded structure in GA may represent an actual granuloma or either diffuse GA or a dense lymphocytic infiltrate as described above. This case suggests that OCT images granulomatous tissue as absorbent, hyporeflective areas, and urate crystals appear as reflective areas, obscuring the underlying tissue. In GA a new image shape looking like a wing has been found. The frequency, specificity and sensitivity of this new pattern in OCT imaging will require further studies.