9 years of age Greater than 50% will leave cutaneous sequelae after involution Unlike infantile hemangiomas, congenital hemangiomas are present at birth and may either rapidly involute over 18 months or persist throughout life Infantile hemangiomas can be subdivided into three types as follows: Superficial hemangiomas are confined to the upper dermis Formerly called capillary or strawberry hemangiomas , these lesions are red, raised, well demarcated, and compressible ( Fig 120.16 ) Deep hemangiomas lie in the lower dermis or subcutaneous fat Formerly called cavernous hemangiomas, these tend to have indistinct margins, and the overlying skin often has a bluish hue ( Fig 120.17 ) On close inspection, many hemangiomas have a combination of both superficial and deep elements, and thus are called mixed hemangiomas FIGURE 120.16 Superficial hemangioma of hand (Reprinted with permission from O’Doherty N Atlas of the Newborn Philadelphia, PA: JB Lippincott; 1979.) FIGURE 120.17 Deep hemangioma of face (Courtesy of Andrea L Zaenglein, MD In: Chung EK, Atkinson-McEvoy LR, Lai NL, et al., eds Visual Diagnosis and Treatment in Pediatrics 3rd ed Philadelphia, PA: Wolters Kluwer Health; 2014 With permission.) Because of their natural history of ultimate regression, a combination of watchful waiting and parental reassurance remain the standard of care for most infantile hemangiomas However, active intervention is indicated for lesions that compromise vital structures (airway, eyes, nose); lesions that are susceptible to trauma, hemorrhage, or infection; and those that grow at an alarming rate Infants who present with stridor at to 12 weeks of age may have an undiagnosed laryngeal hemangioma Nearly two-thirds of infants with laryngeal hemangiomas have cutaneous hemangiomas along the mandible and neck region in a “beard” distribution Infants with greater than five hemangiomas warrant imaging for visceral hemangiomas, specifically liver hemangiomas Infants with large cutaneous or liver hemangiomas are at risk for congestive heart failure Large hemangiomas on the face or scalp, usually greater than cm, have been associated with PHACE syndrome Hemangiomas over the lumbar spine or pelvic region may be a marker for underlying congenital malformations of the spinal cord, genitourinary, or anorectal structures Beta blockers may facilitate resolution for infantile hemangiomas, but should not be prescribed in the ED Decisions regarding medical or interventional treatments are best made by a vascular anomalies specialist Lipoma Lipomas are benign subcutaneous tumors composed of mature adipose cells They often present in adolescence as painless and usually solitary nodules They may be located anywhere on the body Clinically, lipomas are nontender and have a soft, rubbery consistency, often with lobulations Overlying skin is normal and easily slides across the mass, which helps distinguish lipomas from other skin nodules such as pilomatricomas Several lipomas can indicate an underlying syndrome, such as Gardner syndrome discussed earlier, and would necessitate referral to a genetics team to evaluate for associated abnormalities Angiolipomas are a variant of lipoma that has a component of capillary proliferation Unlike lipomas, they tend to be painful Lesions that are cosmetically significant, large, or painful warrant elective surgical excision Lipoblastomas or lipoblastomatosis are also benign subcutaneous tumors, however contrary to lipomas which contain mature adipose cells, lipoblastomas contain immature adipose cells These tumors present in infants and young children as opposed to adolescence and they may have abnormal overlying skin Treatment is surgical excision Lipoblastomas may be difficult to differentiate histologically from myxoid liposarcoma which is the most common liposarcoma in children and can be widely metastatic However, myxoid liposarcomas rarely present in children less than 10 years old, while lipoblastoma presents in younger children Pilomatricoma Pilomatricomas (calcifying epitheliomas) are relatively common lesions, accounting for 10% of superficial nodules seen in children These slow growing benign tumors arise from cells of the hair matrix, hair cortex, or inner root sheath and usually present in school-aged children Most are found on the head and neck, but some arise on the trunk and extremities They appear as firm (resulting from calcification), mobile, solitary nodules ranging in size from 0.5 to cm They are usually painless, but may be mildly tender An overlying bluish hue may help distinguish the lesion from other benign nodules such as epidermal or dermoid cysts When pinched, the overlying skin “tents,” providing another distinguishing feature Multiple pilomatricomas have been associated with Gardner syndrome, Steinert disease, myotonic dystrophy, and sarcoidosis Familial occurrences have been reported but are rare If the lesion is located in a cosmetically sensitive area, elective surgical excision is the treatment of choice since these not spontaneously regress Malignant pilomatrical carcinoma is rare, but possible in children, and therefore benign pilomatricomas require careful observation Pyogenic Granuloma A pyogenic granuloma (also called lobular capillary hemangioma ) is a benign vascular lesion most commonly found on exposed skin surfaces such as the face, hands, and forearms Occasionally, lesions form on oral or nasal mucosal surfaces They are composed of granulation tissue with significant vascular overgrowth and are considered the result of an exaggerated vascular growth factor response after local trauma Lesions are usually solitary and pedunculated, measuring from 0.5 to cm At times, multiple satellite lesions are found around a central granuloma The color and character of a pyogenic granuloma varies according to its stage of growth Early on, the lesion appears as a glistening, red, polypoid nodule with a friable surface that bleeds easily Over weeks to months, most lesions become fibrotic and shrink, taking on a reddish-brown hue The most common reasons for presenting to the ED are bleeding or chronic oozing of an early lesion Treatment in the ED consists of control of bleeding by direct pressure or silver nitrate cauterization of vessels at the base Hemostatic dressings may also be helpful Topical, intralesional, and systemic medical therapy have been reported However, given high reoccurrence rates, surgical excision by a specialist is the preferred treatment Umbilical Granuloma An umbilical granuloma presents as a soft, friable, polypoid mass that is pink or dull red As oppose to omphalitis, umbilical granulomas have a nonpurulent odorless discharge These lesions arise from the base of the umbilical stump after cord detachment and at times may be pedunculated with a short stalk ( Fig 120.18 ) They develop as the product of an exuberant granulation tissue reaction, probably secondary to excessive moisture and/or low-grade infection Histology shows vascular endothelial cells and fibroblasts Treatment of most lesions consists of cauterization with silver nitrate During this procedure, care should be taken to cover the skin of the umbilical rim with gauze and/or petroleum jelly to protect it from chemical burns Following cauterization, the lesion should be blotted dry to avoid seepage of excess silver nitrate to surrounding tissue which can lead to hyperpigmented staining Home care consists of keeping the umbilicus clean and dry Large granulomas may require repeated cautery at intervals of several days Pedunculated granulomas are candidates for suture ligation (3-0 nylon) The parent is then instructed to return for follow-up for cauterization of the base (once the granuloma has necrosed and fallen off) to prevent recurrence Umbilical granulomas must be differentiated from a persistent embryonic remnant such as an omphalomesenteric duct or patent urachus The ... Zaenglein, MD In: Chung EK, Atkinson-McEvoy LR, Lai NL, et al., eds Visual Diagnosis and Treatment in Pediatrics 3rd ed Philadelphia, PA: Wolters Kluwer Health; 2014 With permission.) Because of their