Pediatric Dermatology Consult

A 4-year-old with a lesion on her cheek, which grew and became firmer over two months

A 4-year-old female is brought to our pediatric dermatology clinic for evaluation of a persistent lesion on the cheek.

The mother of the child reports that the lesion started as a small "bug bite" and then started growing and getting firmer for the past 2 months. The girl has developed other smaller red, pimple-like lesions on the cheeks and one of them is starting to increase in size.
She denies any tenderness on the area or any purulent discharge. She has had no fevers, chills, weight loss, nose bleeds, fatigue, or any other symptoms. The mother has not noted any changes on the child's body odor, any rapid growth, or hair on her axillary or pubic area. She was treated with three different courses of oral antibiotics including cephalexin, trimethoprim/sulfamethoxazole, and clindamycin, as well as topical mupirocin, with no improvement.
Her past medical history is significant for several episodes of eyelid cysts that were treated with warm compresses and topical erythromycin ointment. The family history is significant for the father having severe acne as a teenager. She has two cats, she has not traveled, and she has an older sister who has no lesions.
On physical examination she is a lovely 4-year-old female in no acute distress. Her height is on the 70th percentile and weight on the 40th percentile for her age. Her blood pressure is 95/84 with a heart rate of 96. On skin examination she has several pink macules and papules on her bilateral cheeks. On the left cheek there are two pink nodules: One is 1 cm, and the other is 7 mm. The nodules are not tender. There is no warmth, fluctuance, or discharge from the lesions.
She has no cervical lymphadenopathy. She has no axillary or pubic hair. She is Tanner stage I.

What's the diagnosis?

Childhood acne

Childhood rosacea


Idiopathic facial aseptic granuloma

Leukemia cutis

The patient was diagnosed with idiopathic facial aseptic granuloma (IFAG) based on the clinical findings, as well as the associated history of chalazia and erythematous papules seen in childhood rosacea.

Dr. Catalina Matiz

She was treated with several months of azithromycin, sulfur wash, and metronidazole cream with improvement of some of the smaller lesions but no change on the larger nodules. Later she was treated with oral and topical ivermectin with no improvement. Some of the nodules slowly resolved except for the larger lesion on the right cheek. She was later treated with a 6-week course of clarithromycin with partial improvement of the nodule. The lesion resolved after 2 months of stopping clarithromycin.

IFAG is a rare condition seen in prepubescent children. The etiology of this condition is not well understood and is thought to be on the spectrum of childhood rosacea.1 From several recent reports, IFAG usually is seen in children with associated conditions including chalazia, conjunctivitis, blepharitis, and telangiectasias, which can be seen in patients with rosacea. These associated findings suggest the possibility of IFAG being a form of granulomatous rosacea in children. Our patient presented with several lesions on the cheek and had a previous history of recurrent chalazia.

This condition presents in childhood between the ages of 8 months and 13 years. Most of the cases occur in toddlers, and girls appear to be more affected than boys. The lesions appear as pink, rubbery, nontender, nonfluctuant nodules on the cheeks, which can be single or multiple. A large prospective study in 30 children demonstrated that more 70% of the lesions cultured were negative for bacteria. Histologic analysis of some of the lesions showed a chronic dermal lymphohistiocytic granulomatous perifollicular infiltrate with numerous foreign body–type giant cells.2

The differential diagnosis of these lesions should include infectious pyodermas such as mycobacterial infections, cutaneous leishmaniasis, and botryomycosis; deep fungal infections such as sporotrichosis, coccidioidomycosis, and cryptococcosis; childhood nodulocystic acne; pilomatrixoma; epidermoid cyst; vascular tumors or malformations; and leukemia cutis.3

The diagnosis is usually clinical but in atypical cases a skin biopsy with tissue cultures should be performed. The decision to biopsy these lesions will need to be done in a one by one basis, as a biopsy may leave scaring on the area affected.

It has been postulated that a color Doppler ultrasound of the lesion may be a helpful ancillary study. Echographic findings show a well demarcated solid-cystic, hypoechoic dermal lesion, the largest axis of which lies parallel to the skin surface. The lesion lacks calcium deposits. Other findings include increased echogenicity of the underlaying hypodermis. The findings may vary depending on the stage of the lesion.4

The course of the condition may last on average months to years. Some lesions resolve spontaneously and others may respond to courses of oral antibiotics such as clarithromycin, azithromycin, or ivermectin. In our patient, several lesions improved with oral antibiotics, but the larger lesions were more persistent and resolved after a year.

The lesions usually resolve without scarring. In those patients with associated rosacea, maintenance topical treatments may be warranted and also may need follow-up with ophthalmology because they tend to commonly have ocular rosacea as well.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She said she had no relevant financial disclosures. Email her at [email protected].


1. Pediatr Dermatol. 2013 Jan-Feb;30(1):109-11.

2. Br J Dermatol. 2007 Apr;156(4):705-8.

3. Pediatr Dermatol. 2018 Jul;35(4):490-3.

4. Actas Dermosifiliogr. 2019 Oct;110(8):637-41.

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