Most Missed Question in Pediatric Emergency Medicine This Week

A 1-day-old female neonate is found to have a rash above her left eye on examination. She was born at 40 weeks via spontaneous vaginal delivery requiring vacuum assistance. The neonate required blow-by oxygen upon delivery and had a delayed bath.

The neonate has been bottle-feeding well and has had 2 wet diapers and 1 meconium stool. Her vital signs have been normal since the delivery.

On examination, she is sleeping comfortably. She has dull pink macules 0.5 cm in size on her glabella, eyelids, and upper lip. She also has a left-sided cephalohematoma. There is no conjunctivitis or eyelid edema, and her extraocular movements are intact. She has no jaundice. Her lungs are clear; she has no murmur and no organomegaly. The rest of the examination is normal.

The Figure demonstrates the appearance of the dermatologic lesions.

What is the probable course of the facial lesions?

Answers:

1. fading almost completely within 3 weeks
2. fading almost completely within 3 years
3. enlarging rapidly during the first year, then spontaneously involuting within 3 years
4. deepening and enlarging within 3 years, requiring laser therapy for complete resolution
5. no change in size or color over time

Everyone keeps picking infantile hemangioma (#1).  The correct answer is (#2) - salmon patches.  Though they often resolve in 1 to 2 years.  The clue is in the location.

Why This Question Is Often Missed

– Confusing salmon patch with infantile hemangioma: Both are vascular birthmarks, but hemangiomas proliferate before involution, whereas salmon patches do not grow.

– Overlooking lesion location: Salmon patches on the glabella/eyelids (“angel’s kiss”) fade rapidly, whereas those on the nape (“stork bite”) often persist—test-takers who don’t recall this nuance pick the wrong timeline.

What the Distractors Indicate

High-Yield Pearl

Salmon-patch “angel’s kisses” on the face fade spontaneously—usually disappearing by age 1–2, and nearly always by age 3.

Core Learning Objectives

1. Recognize salmon patches: Identify flat, pink macules on the glabella and eyelids that blanch and do not proliferate.
2. Counsel on natural history: Understand that facial salmon patches resolve within the first 1–3 years without intervention.

The “Test Trick” at Play

The question pairs a flat vascular lesion with a cephalohematoma and growth-phase distractors to lure you toward infantile hemangioma timelines—focus instead on the lesion’s morphology (flat, dull pink, non-proliferative) and location.

Additional Practice Questions and Remediation

Question 1

A 3-day-old male has a pink midline patch on the nape of his neck, 1 cm in diameter. It blanches with pressure and the baby is otherwise well. What is the most likely natural history?

1. Persisting unchanged into adulthood
2. Fading almost completely by age 1 year
3. Rapid enlargement in the first 3 months, then involution by age 5 years
4. Progression to a nodular hemangioma requiring excision

Question 2

A 2-week-old infant has a solitary, sharply demarcated, non-blanching purple patch on the right upper eyelid. What is the next best step?

1. Observe, most purple eyelid patches fade by age 3
2. Refer for ophthalmology evaluation
3. Start propranolol therapy immediately
4. Schedule pulsed-dye laser at 6 months

Question 3

A newborn exhibits multiple faint, pink macules on the eyelids that disappear with crying. Which statement is true?

1. They predict underlying cardiac anomalies
2. They are port-wine stains requiring laser therapy
3. They blanch completely and resolve by age 2
4. They indicate trisomy 21

Mini Case Discussion Prompt

How would your clinical approach and parental counseling differ if the lesion had a unilateral sharp border, did not blanch fully, and persisted beyond age 3?