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traumatized areas) ( Fig 88.10 ) JXG lesions may also look like xanthomas Unlike xanthomas, however, abnormal lipid levels not occur with JXGs FIGURE 88.8 Pyogenic granuloma FIGURE 88.9 Urticaria pigmentosa with Darier sign Mastocytoma, Urticaria Pigmentosa These are red/brown papules that urticate For additional information please see Chapter 69 Rash: Neonatal Juvenile Xanthogranulomas Juvenile xanthogranuloma JXGs can be confused with urticaria pigmentosa or xanthomas Numerous yellow or reddish-brown papules appear on the face and upper trunk in the first year of life The number of lesions may increase until the child is 18 months to years of age Serum lipid levels are normal, and the Darier sign (urtication after scratching) is negative The lesions often disappear spontaneously after years of age; therefore, intervention is generally unnecessary When JXGs are multiple, particularly on the head and neck, evaluation of the eyes for intraocular JXGs is recommended because of their potential for visual impairment The presence of JXGs in a young child with neurofibromatosis (type 1) has been a marker associated with an increased risk of juvenile myelomonocytic leukemia FIGURE 88.10 Juvenile xanthogranuloma (JXG) Skin-Colored Papules Many entities may present as skin-colored papules Here we will highlight lichen striatus and lichen nitidus When the papules are arranged linearly, streaming down an extremity or across the face or neck, lichen striatus should be considered If the papules are not arranged linearly but are tiny pinpoint, skincolored papules, lichen nitidus should be considered, especially if a Koebner phenomenon is present Flat warts may be skin colored as well Lichen Striatus Lichen striatus is an asymptomatic eruption of unknown cause The flat-topped papules are arranged linearly and may be confluent Lesions may occur in a wide band but remain characteristically linear or more accurately curvilinear patterns corresponding to lines of Blaschko The lesions are skin colored to erythematous in Caucasians and often hypopigmented in African Americans The eruption follows the long axis of an extremity ( Fig 88.11 ) or may involve any other part of the skin surface (especially the face) Because the eruption resolves spontaneously within years, no treatment is necessary Lichen Nitidus Lichen nitidus is characterized by tiny, pinpoint, flat-topped, skin-colored papules ( Fig 88.12 ) The papules are often grouped and are found in scratch lines (i.e., the Koebner phenomenon) Although any skin surface may be involved, the trunk and genitalia are common sites The lesions are often asymptomatic but may occasionally itch The lesions persist for variable periods and generally not respond to therapy PLAQUES Annular Plaques Granuloma Annulare Granuloma annulare is believed to be an idiosyncratic response to trauma and looks to many like tinea corporis (“ringworm”) without the scale This skin change may begin as a skin-colored or violaceous papule that clears centrally as the margins advance, or it may appear as a group of papules arranged in a ringlike configuration ( Fig 88.13 ) The central portion of the lesion is often dusky or hyperpigmented The key point on physical examination is the lack of scaling This physical finding distinguishes granuloma annulare from tinea corporis The border is firm on palpation, unlike tinea corporis The rings can be cm in diameter or larger FIGURE 88.11 Lichen striatus