A non‐healing perianal ulceration

A 2-week-old infant was seen in the emergency department (ED) because of a non-healing perianal ulceration. A faint perianal erythema was noted by the parents at 1 week of life and was initially thought to be a mild irritant dermatitis from frequent stooling on presentation to the general practitioner. At the time, she was passing up to 9 loose stools a day, yellow in colour, without blood or mucus. Topical zinc oxide barrier cream, frequent diaper changes and gentle cleaning with warm water were prescribed to manage the diaper rash. Despite these measures, 3 days later, ulceration developed and rapidly worsened over the next week. On examination, an extensive midline, deep-seated, punched-out ulcer involving the lower sacral area and extending into the anal verge was found. The base of the ulcer was clean, with granulation tissue present (Fig. 1a). The infant looked well, and no other skin abnormalities or ulcers were found elsewhere on full skin and mucosal examination. What is the diagnosis? (Answer on page ••). This patient has a variation of haemangioma known as infantile haemangioma with minimal or arrested growth presenting as a non-healing perianal ulceration. The diagnosis was confirmed by skin biopsy demonstrating strong diffuse positive GLUT1 immunostaining at the endothelial lining of the dermal vessels.1, 2 The arrested growth pattern explains the atypical appearance and the ulceration in the perianal area can possibly be explained by the fact that the early developing lesion is irritated by urine and faeces and traumatised by the necessary cleaning of the area.3-5 The perianal ulceration showed a rapid response with complete healing within 4 months of propranolol initiation (Fig. 1b). The morphology and location posed a diagnostic dilemma and required multidisciplinary evaluation to exclude alternate pathologies, including infantile inflammatory bowel disease, immunodeficiency disorders, a large segmental haemangioma and LUMBAR syndrome. This case highlights the importance of including infantile haemangioma among the differential diagnoses in neonates presenting with rapid onset perianal ulceration. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australian University Librarians.