Clinical Challenge: Red Lesion on the Cheek - MPR

Clinical Challenge: Red Lesion on the Cheek

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A 12-month-old girl is referred for evaluation of a skin lesion on her left cheek. According to her parents, the lesion was visible at birth and looked like “a red speck.” The lesion grew to its present size over the first 6 months of life. The child’s older sibling, a 2-year-old boy, has no similar lesions. Examination of the lesion reveals a 0.6-cm erythematous papule. No other cutaneous abnormalities are noted.

Infantile or strawberry hemangiomas are the most common benign skin lesions to affect infants, occurring in approximately 5% of babies.1,2 Most lesions, but not all, are present at birth and rapidly grow throughout infancy (proliferative phase). The majority of lesions obtain...

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Infantile or strawberry hemangiomas are the most common benign skin lesions to affect infants, occurring in approximately 5% of babies.1,2 Most lesions, but not all, are present at birth and rapidly grow throughout infancy (proliferative phase). The majority of lesions obtain maximum size by 3 to 5 months. Deep infantile hemangioma is a less common subtype of infantile hemangioma that manifests subcutaneously and appears blue or skin colored.These lesions tend to grow later and longer than superficial hemangiomas.2

Parents are often alarmed by what appears to be a tiny scratch or bruise that rapidly grows into a bright-red, raised lesion. In general, these lesions will resolve spontaneously (involution phase) and not require intervention.3 More aggressive intervention is required for high-risk lesions that are accompanied by functional impairment or ulceration. Lesions of the lip, for example, are prone to ulceration, whereas those on the mid cheek and nose are associated with increased risk for disfigurement or permanent distortion of anatomic landmarks.

Oral propranolol was first reported to involute severe infantile hemangiomas in 2008 and received US Food and Drug Administration indication for this condition in 2014.4,5 This treatment is now considered the gold standard of therapy but requires careful monitoring of blood pressure and serum glucose levels.1 A death from a related β-adrenergic antagonist, nadolol, used to treat an infantile hemangioma in a 10-month-old infant, has been reported.6 Topical timolol has also demonstrated a high degree of efficacy and is a safer alternative to systemic therapy.7,8

Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.

References

 1. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical practice guideline for the management of infantile hemangiomas. Pediatrics. 2019;143(1).

2. Chang LC, Haggstrom AN, Drolet BA, et al. Growth characteristics of infantile hemangiomas: implications for management. Pediatrics. 2008;122(2):360-367.

3. Darrow DH, Greene AK, Mancini AJ, Nopper AJ. Diagnosis and management of infantile hemangioma: executive summaryPediatrics. 2015;136(4):786-791.

4. Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancyN Engl J Med. 2008;358(24):2649-2651.

5. Hemangeol™ [package insert]. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc; 2014.

6. McGillis E, Baumann T, LeRoy J. Death associated with nadolol for infantile hemangioma: a case for improving safetyPediatrics. 2020;145(1):e20191035.

7. Püttgen K, Lucky A, Adams D, et al. Topical timolol maleate treatment of infantile hemangiomas. Pediatrics. 2016;138(3):e20160355.

8. Lin Z, Zhang B, Yu Z, Li H. The effectiveness and safety of topical β-receptor blocker in treating superficial infantile haemangiomas: a meta-analysis including 20 studies [published online December 13, 2019]. Br J Clin Pharmacol. doi: 10.1111/bcp.14196.