A pimple-like lesion on the cheek of a 5-year-old girl.

Presentation A healthy-appearing 5-year-old girl comes to the dermatology clinic for evaluation of a lesion on her face that has been present for at least 3 years. The lesion started as a pimple-like growth on her left superior cheek near the lower eyelid, subsequently grew in size, but has been stable in size for the past 1 to 2 years. The lesion is only occasionally tender when bumped, but the patient and parents report no precipitating trauma to the area. The lesion previously was believed to be a wart and was treated with imiquimod (a topical immune response modifier used to treat superficial basal cell carcinoma, actinic keratosis, and external genital and perianal warts), but no significant change was seen after approximately 2 weeks of use. Later, a primary care physician applied liquid nitrogen cryotherapy to the lesion, resulting in only some superficial sloughing. The patient was seen by another dermatologist, who again prescribed imiquimod for the presumed wart, but the parents chose to get another opinion. The patient’s past medical and surgical history includes prior eustachian tube dysfunction requiring pressure-equalization tubes and a severe reaction to chickenpox requiring hospitalization. Her perinatal history is unremarkable. She is taking no medications. On physical examination, the lesion is a 6-mm, raised, erythematous papule that is semifirm to palpation (Figs. 1 and 2). No underlying dermal component is appreciated; under epiluminescence microscopy (also known as dermoscopy), the lesion appears to have prominent vascularity. No other lesions are noted on the face, neck, and scalp. Because of the location of the lesion on the face, the patient is referred to the plastic surgery department for removal. The lesion is excised, and on the basis of pathologic findings, a diagnosis is suspected.