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An 8-year-old girl with a bleeding red bump
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An otherwise healthy 8-year-old girl presented to clinic with a 3-week history of a growing red bump on her back. She reported that it bled one time after traumatizing the area.
On examination, there was a 5-mm bright red papule with a collarette of scale on a background of unremarkable skin. She also had adhesive residua from an adhesive bandage that was kept on top of the lesion.
She took no oral medications and had no prior treatments to the area. She generally felt well and denied fevers or chills.
Source: Aditi Murthy, MD
There was no family history of similar appearing lesions.
Can you spot the rash?
A. Infantile hemangioma
B. Spitz nevus
C. Amelanotic melanoma
D. Insect bite
E. Pyogenic granuloma
Case Discussion
Pyogenic granuloma (PG) is a relatively common benign vascular neoplasm of the skin in children. These lesions occur most commonly in infants and young children but can be seen at any age. They appear as bright, red vascular papules, often pedunculated, with a collarette of scale at the base. Families usually report the sudden growth of a bright red papule and often present to clinic because of troublesome bleeding episodes.
Many patients present with a so-called “Band-Aid” sign from having constant dressings over the lesion. Although most often idiopathic, development of PG can be trauma related, as well as related to exposure to certain medications, such as isotretinoin.
For bleeding or symptomatic PG, our typical first approach is to perform shave or curettage removal of the lesion in the office and send the specimen to pathology to rule out an atypical melanocytic lesion. Other treatment approaches for classic PG include topical beta-blockers, such as timolol or pulsed-dye laser. There are also reports in the literature of topical imiquimod being used successfully for the treatment of PG. PG typically do not self-resolve without treatment.
Important in the differential diagnosis of pyogenic granuloma are melanocytic lesions such as Spitz nevi or rarely, amelanotic melanoma. Spitz nevi are a type of acquired nevi in childhood that can present as pink-brown, dome-shaped, smooth papules or dark brown macules or papules. They tend to grow very quickly and can self-resolve in some cases. Spitz nevi have a characteristic histology but on gross exam can be very difficult to differentiate from amelanotic melanoma. For Spitz nevi with atypical histology, management is controversial.
Amelanotic melanoma, although rare, is an important consideration in the differential diagnosis of a new bleeding pink papule in a child. These lesions can also arise rapidly, and biopsy is crucial to the diagnosis.
An insect bite could be considered in the differential diagnosis of a solitary pink papule; however, it would be very unusual for a presenting complaint to be bleeding. Insect bites usually are pruritic and tend to favor exposed areas of skin, such as the distal lower extremities, and they resolve in several days.
Finally, a new-onset infantile hemangioma (IH) would be highly unlikely in this age group. The classic history of IH is the presence of a faint red precursor lesion at birth or shortly after, with proliferation to a vascular papule or plaque in the first few months of life. IH then has a plateau phase and an involutional phase, with a majority of lesions involuting by age 5 years. These lesions differ from pyogenic granuloma in that they are typically not as friable and are much less likely to bleed.
- References:
- Dika E, et al. Pediatr Dermatol. 2017;doi:10.1111/ped.13025.
- Knöpfel N, et al. J Am Acad Dermatol. 2016;doi:10.106/j.jaad.2016.03.036.
- Paller AS, et al. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 5th ed. Elsevier; London; 2016.
- Tritton SM, et al. Pediatr Dermatol. 2009;doi:10.1111/j.1525-1470.2008.00864.x.
- For more information:
- Aditi Murthy, MD, is a pediatric dermatology fellow at The Children’s Hospital of Philadelphia. She can be reached at MurthyA1@email.chop.edu.
- Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia.
Disclosures: Murthy and Perman report no relevant financial disclosures.