Insufficient questioning

Facial dermatosis
Paediatric dermatology

Dr. Emmanuelle Bourrat

Saint-Louis Hospital

The clinical case
Now it's your turn!
Co-prescription and advice

Clinical case presentation

This 4-year-old boy with no previous history consulted us in November for a progressive erythematous papule on the right cheek that had appeared in April of the same year. The parents reported no traumatic or other potentially triggering factors.

The lesion was neither painful nor pruritic but had been slightly excoriated by the child's self-manipulation, so the parents preferred to protect it with a bandage.

Examination showed an erythematous papule 8 mm in diameter with a smooth surface punctuated by small hemorrhagic remodeling on the surface and surrounded by an eczematous appearance attributed to intolerance of the adhesive.

The rest of the examination was normal; despite a nonspecific dermoscopic appearance, the diagnosis evoked was that of a Spitz nevus, common at this age and in this location. An excision without margin under local anesthetic was proposed given the non-typical and progressive nature of the lesion.

Your turn

What is your diagnosis?

Select 1 answer(s) from the following choices:

Leishmaniasis

Spitz melanoma

Pyogenic granuloma

Borrelial lymphocytoma

Wrong answer!

Good answer!

Selected diagnosis

The histological result of this lesion came as a surprise since it revealed cutaneous leishmaniasis! Further questioning revealed regular stays in Tunisia, the last of which had been 8 months before the appearance of the papule.

At the postoperative checkup, the lesion had not disappeared and continued to evolve, this time with a typical appearance of leishmaniasis. The parents agreed to abstain from treatment in view of the minor cosmetic impact and the expected good spontaneous prognosis of this dermatosis.

Spitz nevus in prepubertal children is by definition a benign lesion, but this benign character is sometimes very difficult to confirm. In a certain number of cases, only excision with expert histopathological analysis coupled with immunostaining, or even somatic molecular study, can rule out a spitzoid lesion of indeterminate prognosis or an exceptional Spitz melanoma.

In this case, excision has enabled a differential diagnosis that a more thorough history would have suggested!

Explanation of wrong answers

Spitz's melanoma: Any spitzoid lesion in children that is atypical in terms of topography, clinical appearance, evolution or age range should be removed to rule out a malignant lesion.
Pyogenic granuloma: This more or less epidermized fleshy bud bleeds readily on contact and usually follows superficial trauma that may have gone unnoticed. Treatment is usually surgical, which helps confirm the diagnosis.
Borrelial lymphocytoma: A pinkish or red papule with no epidermal signs, corresponding to a secondary phase of borreliosis. Diagnosis is histological (benign B-cell lymphocytic proliferation) if there is no evidence of tick bite and/or preexisting erythema migrans.

Treatment

This is no longer an issue in this case, as the lesion was surgically removed.

Old World cutaneous leishmaniasis in children is a dermatosis that eventually regresses spontaneously over a variable period of time but may leave a permanent scar.

In cosmetically exposed areas, local treatment may be considered: local injection of Glucantime, topical aminoglycoside cream, etc.

Message from the expert

Leishmaniasis is a deceptive dermatosis because it is protean: questioning to find out whether you have been in an endemic area, even for a short time, is therefore of the utmost importance!

References

^{Sitenga G, Aird J, Wieland C, Moran SL, Tollefson M. An unusual pediatric case of atypical spitzoid neoplasm.}^{Pediatr Dermatol. 2021 Sep;38(5):1255-1257.}