Treatment with cortisone has been successfully de- scribed in only 10% of reported cases and with interferon alpha in only 50% to 60% (2). Partial remission has previously been reported with the use of interferon alpha in combination with vincristine and cyclophosphamide in single case reports. Although vincristine is often used as a third-line therapy (3), in this case, a marked improvement was appreciated soon after introducing this drug, after poor response to previous treatment with corticosteroids and interferon alpha. Pharmacologic agents that affect hemostasis (such as ticlopidine and aspirin, dipyridamole, pentoxiphylin, and heparin) have been used in some cases (1,4,5). Smaller lesions may be surgically excised, but many tumors can only be treated medically because of their location or size (1). In our case, surgery was not performed due to the age of the patient and the size of the tumor. Arterial embolization was considered but was not attempted because the tumor was fed by three important vessels. Our case adds to the growing body of literature suggesting that alternatives to corticosteroids and interferon, particularly vincristine (6) should be considered. REFERENCES 1. Zukerberg LR, Nickoloff BJ, Weiss SW. Kaposiform hemangioendothelioma of infancy and childhood: and aggressive neoplasm associated with Kasabach-Merritt syndrome and lymphangiomatosis. Am J Surg Pathol 1993;17:321–328. 2. Sarkar M, Mulliken JB, Kozakewich HP et al. Thrombo- cytopenic coagulopathy (Kasabach-Merrit phenomenon) is associated with Kaposiform hemangioendothelioma and not with common infantile hemangioma. Plast Reconstr Surg 1997;100:1377–1386. 3. Hauer J, Graubner U, Konstantopoulos N et al. Effec- tive treatment of kaposiform hemangioendotheliomas associated with Kasabach-Merritt phenomenon using four-drug regimen. Pediatr Blood Cancer 2007;49:852– 854. 4. Vin-Christian K, McCalmont TH, Frieden IF. Kaposiform hemangioendothelioma. An aggressive, locally invasive vascular tumor that can mimic hemangioma of infancy. Arch Dermatol 1997;133:1573–1578. 5. Mulliken JB, Boon LM, Takahashi K et al. Pharmacologic therapy for endangering hemangiomas. Curr Opin Derma- tol 1995;2:109–113. 6. Haisley-Royler C, Enjolras O, Frieden IJ et al. Kasabach-merritt phenomenon: a retrospective study of treatment with vincristine. J Pediatr Hematol Oncol 2002;24:459–462. VERO ´ NICA LO ´ PEZ, M.D.* NURIA MARTI ´ , M.D.* CAROLINA PEREDA, M.D.* JOSE ´ MARI ´ A MARTI ´ N, M.D.* DOLORES RAMO ´ N, M.D.* EMPAR MAYORDOMO, M.D.  ESPERANZA JORDA ´ , M.D., PH.D.* Departments of *Dermatology and  Pathology, Hospital Clı´ nico Universitario de Valencia, Valencia, Spain, PYOGENIC GRANULOMA IN TWO CHILDREN SUCCESSFULLY TREATED WITH IMIQUIMOD 5% CREAM Abstract: Pyogenic granulomas are sometimes difficult to treat in children, especially very young chil- dren in whom surgical procedures may be difficult. Here, we present two children with pyogenic granuloma who were successfully treated by topical imiquimod cream with excellent results. Pyogenic granuloma (PG), also referred to as lobular capillary hemangioma, is a common, acquired, benign vascular proliferation of skin and mucous mem- branes. Although the diagnosis is generally depends upon clinical appearence, differential diagnosis with some other less frequent lesions such as Spitz Nevi and amelanotic melanoma may be possible by dermoscopic examination. Histopathogical evaluation is important if the clinical presentation is not classical or for dermoscopically suspicious lesions. Treatment may be more difficult in some children, who cannot either be held or cooperate with local surgical extir- pation. We report herein on two children with PG are presented who were successfully treated with topical imiquimod. CASE 1 An 8-year-old boy presented with a 4-week history of a ‘‘bleeding wart.’’ The lesion was an 8-mm friable, red, vascular, pedunculated papule at the back of the trunk (Fig. 1A). Dermoscopy demonstrated a red–whitish homogeneous area surrounded by a white collarette, white rail, and a sharply circumscribed, crusted papule. Imiquimod 5% cream bid was applied, five times in a week. One week later, regression was observed with hemorrhagic crusting (Fig. 1B). At the end of 2 weeks, clinical resolution and a good cosmetic result were obtained (Fig. 1C) and application was stopped. No recurrence was observed during 5 months follow-up. Address correspondence to Vero´ nica Lo´ pez, M.D., Department of Dermatology, Hospital Clı´nico Universitario de Valencia, Avda. Blasco Iba´n˜ez, No. 17, 46010 Valencia, Spain, or e-mail: veroni- cal_c@hotmail.com. 366 Pediatric Dermatology Vol. 26 No. 3 May / June 2009