Approach to the Problem
Focal red bumps are common in pediatric patients. Etiologies include self-limited, benign diagnoses such as insect bites and erythema toxicum neonatorum; more serious infectious causes like furuncles, carbuncles, abscesses, and cat-scratch disease; and tumors including hemangiomas, pyogenic granulomas, and Spitz nevi.
Key Points in the History
• Erythema toxicum neonatorum is a common, self-resolving rash seen in newborns with onset in the first 24 to 48 hours of life.
• Insect bites may not have a known exposure. Household members may be affected differently, with younger patients experiencing more pronounced local reactions.
• Furuncles, carbuncles, and abscesses are more common in patients and families with a history of recurrent skin infections and/or methicillin-resistant Staphylococcus aureus (MRSA) colonization.
• Hemangiomas typically arise between 2 and 4 weeks of age, but may have a precursor lesion that is sometimes detected at birth.
• Hemangiomas have a phase of rapid growth beginning at 4 to 8 weeks of age and continued expansion through 6 to 9 months of age. This is followed by slowed growth and eventual involution beginning in the second year of life. Hemangiomas typically completely involute by age 7 to 9.
• Pyogenic granulomas tend to grow rapidly and bleed easily. They typically arise later in childhood than hemangiomas.
Key Points in the Physical Examination
• Erythema toxicum neonatorum may appear as isolated lesions that resemble flea bites or as coalescent lesions.
• Insect bites, particularly mosquito bites, tend to have induration that is particularly apparent the day after the insect bite. A central punctum can help to distinguish an insect bite from other swelling.
• A furuncle is a deep bacterial folliculitis. Confluence of several adjacent furuncles can create a carbuncle, which can become further organized into a walled-off abscess. These lesions are all typically tender and warm.
• Although pyogenic granulomas can resemble hemangiomas, only the former exhibit a hypopigmented collarette.
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