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The Mysterious Case of the Infant with Red Cheeks

May 20, 2016
Jonathan A. Schneider, DO
Jonathan A. Schneider, DO

Lesions are warm to the touch; exam is unremarkable. Does mom have the answer? Do you?

The Mystery of the Red-cheeked Child

You see a 9-month-old male with acute onset of warm, erythematous cheeks. Immunizations are up-to-date. History is unremarkable.

Non-tender, very erythematous area that shows 2.5 cm of induration on both cheeks.

Erythematous lesions that are warm to the touch on both cheeks.

A partial differential diagnosis: Erythema infectiosum/Fifth’s disease; neonatal lupus; child abuse; panniculitis from something cold; chilblains.

The child has been teething; what has the mother used to assist?

Answer is popsicle panniculitis; a benign, self-limited form of cold panniculitis.

Cold panniculitis: Disorder of subcutaneous fat; a lobular panniculitis characterized by intense inflammation at dermosubcutaneous junction.

There are many types of panniculitis; never assume cold is the answer; systemic diseases such as buccal cellulitis (Haemophilus and Pneumococcal sepsis) can have very similar presentation.

Cold panniculitis caused by a frozen teething ring and by ice chips placed in the mouth.

Panniculitis caused by ice chips used for teething.

Angular cheilitis is another complication of teething rings.

Buccal cellulitis and early orbital cellulitis caused by H. influenzae.

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Indurated annular lesions appeared on this 9-month-old boy's cheeks overnight. He was previously well. Have a virtual seat in the Acute Care Clinic where Dr Jon Schneider and his resident puzzle over the potential causes of these nontender patches. What do you suspect?  

References:

Epstein EH Jr, Oren ME.  Popsicle panniculitis. N Engl J Med. 1970;282:966-967.

Grassi S, Borroni RG, Brazzelli V. Panniculitis in children. Ital Dermatol Venerol. 2103;148:371-385.

Quesada-Cortes A, Campos-Munoz L, Diaz-Diaz R, Casado-Jimenez M. Cold panniculitis. Derm Clinics. 2008;26:485-489.

Rajkumar SV, Laude TA, Russo RM, Gururaj VJ. Popsicle panniculitis of the cheeks. A diagnostic entity caused by sucking on cold objects. Clin Pediatr (Phila). 1976;15:619-21.

Ter Poorten JC, Hebert AA, Ilkiw R. Cold panniculitis in a neonate. J Am Acad Dermatol. 1995;33:383-385.

Schwartz RA. Cold panniculitis. eMedicine Web site. Accessed May 20 and available at: http://www.emedicine.com/derm/topic781.htm.