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The differential diagnosis between infantile hemangioma and pyogenic granuloma is usually easy, especially due to the different time of onset. However, when PG arises in the first months of life or is even congenital (2), the diagnosis, which is important from a prognostic and therapeutic point of view, can present some difficulties. The immunohistochemical criterion of the positivity of GLUT-1 is considered an important discriminating criterion because PG is negative unlike IH, which is positive. However, this criterion, which is very useful for scientific studies, is less useful in clinical practice, because to use it you have to do a biopsy or removal, practices that are not usually performed in IH; and when removal is performed, it means that the physician has already clinically decided that it is PG and in this case the negativity of GLUT-1 only serves to confirm the clinical diagnosis of PG. Therefore the decision on the therapeutic behavior to be adopted in front of a vascular tumor remains essentially clinical.
In some borderline cases, such as the current one, the most important clinical criteria are the implant basis, ulceration and bleeding. PG is usually pedunculated while IH is sessile, at least initially: only rarely, when IH is very large and is located in areas of loose skin, it can become pedunculated with time due to gravity. The most important clinical criterion (1) remains ulceration with consequent bleeding: IH rarely ulcerates, especially in the diaper region, and when ulcerating, bleeding is almost never massive. On the other hand, ulceration, being linked to its rapid growth, is the rule in PG unless it is localized in areas of thick epidermis such as in the palmar region; and the bleeding resulting from ulceration is usually copious, alarming the parents and prompting the doctor to surgically intervene.