A healthy, afebrile, 12-month-old girl presents for evaluation with an asymptomatic nodule on her left cheek that has been present for 3 weeks (Figure 1). She was initially seen by her pediatrician, diagnosed with cellulitis, and prescribed an oral antibiotic, which was not administered by her parents.
Diagnosis: Cold panniculitis
Cold panniculitis is a phenomenon that occurs primarily in infants and young children due to a higher proportion of saturated fats in subcutaneous fat compared with older children and adults.1 Saturated fats become solid with cold exposure at a relatively higher temperature than unsaturated fats, leading to the potential for fat crystallization and adipocyte damage with short exposures to cold.
Development of cold panniculitis after exposure to popsicles and cold environments has been reported particularly in young children.2,3 Additionally, there have been reports of cold panniculitis as a complication of ice pack application to the face and as a vagal maneuver to treat supraventricular tachycardia in newborns.2,4,5 Red, indurated plaques typically develop 24 to 72 hours after exposure, frequently occurring on the cheeks or chin due to a higher amount of subcutaneous fat in these areas.
Whereas a clinical diagnosis can be made by physical examination in the setting of an appropriate history, histopathology is confirmatory but usually not necessary. A lobular panniculitis with a lymphocytic and histiocytic inflammatory infiltrate is present at the junction of the dermis and subcutaneous fat.1,2
Included in the differential diagnosis of cold panniculitis are the other panniculitides seen in the pediatric population. These include subcutaneous fat necrosis of the newborn (SCFN), poststeroid panniculitis, and sclerema neonatorum.6 Subcutaneous fat necrosis of the newborn appears in full-term infants and may be associated with perinatal complications. Erythematous to violaceous indurated plaques or subcutaneous nodules appear within days to weeks of birth. Much of the body can be involved, but the anterior trunk is classically spared.6 Although benign, SCFN should be differentiated from cold panniculitis due to the potential for metabolic derangements, specifically hypercalcemia. The possibility of such complications necessitates clinical monitoring of patients with SCFN.
Post-steroid panniculitis characteristically presents in children who are on high doses of systemic corticosteroids followed by rapid withdrawal.6 Erythematous subcutaneous nodules develop within several days of steroid cessation, most commonly on the cheeks, again attributed to the high concentration of fat in this area as occurs with steroid therapy. The lesions are typically asymptomatic, but they can ulcerate and scar.
1. Quesada-Cortes A, Campos-Munoz L, Diaz-Diaz RM, Casado-Jimenez M. Cold panniculitis. Dermatol Clin. 2008;26(4):485-489, vii.
2. Bolotin D, Duffy KL, Petronic-Rosic V, Rhee CJ, Myers PJ, Stein SL. Cold panniculitis following ice therapy for cardiac arrhythmia. Pediatr Dermatol. 2011;28(2):192-194.
3. Bournas VG, Eilbert W. Infant with facial lesions. Ann Emerg Med. 2011;58(2):216-221.
4. Markus JR, de Carvalho VO, Abagge KT, Percicotte L. Ice age: a case of cold panniculitis. Arch Dis Child Fetal Neonatal Ed. 2011;96(3):F200.
5. Ter Poorten JC, Hebert AA, Ilkiw R. Cold panniculitis in a neonate. J Am Acad Dermatol. 1995;33(2 Pt 2):383-385.
6. Polcari IC, Stein SL. Panniculitis in childhood. Dermatol Ther. 2010;23(4):356-367.