In the absence of a characteristic history for cold panniculitis, punch biopsy can be performed to support the diagnosis and rule out other conditions. Subcutaneous fat necrosis of the newborn is characterized by a radial pattern of needle-shaped crystals on histology.2 Unlike cold panniculitis wherein infiltrates are limited to the upper subcutis, inflammation in SCFN involves the entire subcutaneous fat layer. Post-steroid panniculitis can appear identical to SCFN on biopsy but is easily distinguished with clinical correlation of high dose steroid use.
Sclerema neonatorum is a panniculitis most commonly seen in premature infants with infection or heart disease. Diffuse woody induration starts on the buttocks and thighs, with rapid extension to include other areas of the body. Feeding and respiration can be impaired if involvement is extensive enough to limit movement. Despite the ill appearance of the infant, histology may reveal only mild changes with little to no inflammation.6 Infectious cellulitis may also be considered in the differential diagnosis in the setting of a febrile and ill-appearing infant.
No treatment is required for cold panniculitis. In the setting of an appropriate history and characteristic morphology, the patient can be monitored for improvement. The lesions typically progress from red to purple in color, with gradual improvement of induration. Complete resolution is expected in a period of weeks to months.
On examination, the child was playful and afebrile. Upon further questioning, mother reported that the child lived in Alaska and spent time outside when at daycare.
At the time of this patient’s evaluation, 3 weeks after onset of the rash, the mother reported that the child’s lesion was spontaneously improving. Examination revealed a well-demarcated purple to red plaque, with greatly reduced erythema compared with the initial lesion (Figure 2). The mother was reassured of the benign nature of cold panniculitis and the expectation for full resolution. Ongoing protection from extreme cold exposure was recommended.
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