FIGURE 120.23 Lumbosacral hairy patch in a patient with diastematomyelia Perineal Lesions Hemorrhoids , internal and external , are dilated veins arising from the superior and inferior hemorrhoids veins They can be confused with skin tags, rectal polyps, rectal prolapse, or condylomata acuminate (see Chapter 88 Dermatologic Urgencies and Emergencies ) While very uncommon in children, incidences of hemorrhoids increase during adolescence Development of hemorrhoids is associated with portal hypertension, chronic constipation, or excessive straining Symptoms include painless bleeding (internal hemorrhoids), prolapse, pruritis, and pain secondary to vascular thrombosis Treatment initially starts with medical management, increased fiber consumption or use of stool softeners, and topical care with corticosteroids and analgesics Refractory hemorrhoids may be managed nonoperatively with ablation or ligation If unsuccessful, hemorrhoidectomy should be considered Due to the rarity of hemorrhoids in children, any presentation should prompt a careful and thorough evaluation of the underlying etiology Perianal skin tags are common sequelae of anal fissures and thus tend to be seen in children with a history of large, hard stools They consist of pedunculated masses on short stalks that form during the process of healing of an anal fissure, probably in part caused by frictional forces common to this area They are usually asymptomatic They also can be seen in association with hypertrophic scars, another common sequela of the healing of an anal fissure Although most patients with these lesions are otherwise normal, a small percentage have them as manifestations of perianal disease, internal fissures, and/or fistula, which may be a manifestation of inflammatory bowel disease Management is directed at