Other vascular nodules, including kaposiform hemangioendotheliomas and sarcomas, should be considered when vascular papules or nodules feel firm or not follow the natural history of infantile or congenital hemangiomas Acquired lesions include Spitz nevi and pyogenic granulomas Spitz nevus Spitz nevi appear suddenly between and 13 years of age Preferred sites of growth include the cheek, shoulder, and upper extremities ( Fig 88.7 ) The lesion has a pink to red surface because of numerous dilated blood vessels Pressure produces blanching of this pink to red color The lesions can reach 1.5 cm in diameter but are completely benign Pigmented Spitz nevi, another variant of Spitz nevi, often appear black in the skin rather than pink-red, and their appearance is often worrisome for malignant melanoma Because the histologic appearance of these lesions can be confused easily with a malignant melanoma, an experienced histopathologist should interpret the findings Most clinicians still recommend that Spitz nevi be removed surgically Pyogenic granulomas Pyogenic granulomas ( Fig 88.8 ) are bright red to reddish-brown or blue-black pedunculated, vascular papules/nodules ranging from 0.5 to cm in size that develop rapidly at the site of an injury, such as a cut, scratch, insect bite, or burn Pyogenic granulomas occur commonly in children and young adults, usually on the fingers, face, hands, and forearms They bleed easily Generally, they are asymptomatic Because spontaneous disappearance is rare, patients should be referred for definitive treatment, typically with curettage, excision, electrosurgery, cryosurgery, laser surgery, or some combination of these various modalities