What causes strawberry skin and what are the first‑line treatment options?

Strawberry Skin: Causes and First-Line Treatment

What "Strawberry Skin" Refers To

The term "strawberry skin" has two distinct medical meanings depending on context: in rhinology it describes the endoscopic appearance of sinonasal sarcoidosis, while in pediatrics it refers to superficial infantile hemangiomas.

Sinonasal Sarcoidosis ("Strawberry Skin" Appearance)

In adults presenting with nasal symptoms, "strawberry skin" describes the characteristic endoscopic finding of sarcoidosis—small pale granulomas dotted over erythematous and granular nasal mucosa. 1

Clinical Presentation

• Nearly 90% of patients experience nasal congestion or blockage 1
• Two-thirds develop crusting, 40% have bleeding or spotting, and approximately 25% experience facial symptoms 1
• The co-existence of chronic rhinosinusitis with two of the following is highly specific for sarcoid: nasal crusting, anosmia, and epistaxis 1
• The inferior turbinate and adjacent nasal septum show nodular hypertrophy, though any paranasal sinus can be involved 1

Diagnostic Approach

• Biopsy the nasal mucosa if it appears macroscopically abnormal—91% will be positive for non-caseating granulomas 1
• Blood tests may show raised serum angiotensin-converting enzyme (60-83% sensitivity), hypercalcemia (10-13%), or raised alkaline phosphatase, though none are diagnostic 1
• CT scanning often shows non-specific generalized opacification similar to chronic rhinosinusitis, with possible turbinate or septal nodularity (21%), osteoneogenesis (15%), or bone erosion (8%) 1

First-Line Treatment

The evidence provided does not specify first-line treatment for sinonasal sarcoidosis, as this typically requires systemic management by pulmonology or rheumatology in conjunction with ENT specialists for symptomatic nasal disease.

Superficial Infantile Hemangiomas ("Strawberry Hemangiomas")

In infants, "strawberry skin" or "strawberry hemangiomas" are superficial infantile hemangiomas—benign vascular tumors that appear as red, raised lesions with little subcutaneous component. 1

Natural History and Risk Stratification

• These lesions develop during the first weeks or months of life, undergo rapid growth (accelerated between 5-7 weeks of age), then gradually involute spontaneously 1
• Over 95% of untreated lesions involute satisfactorily without intervention 2
• However, 55-69% of untreated hemangiomas in referral settings result in permanent skin changes, particularly those with prominent thick superficial components and steep step-off from normal skin 1

High-Risk Features Requiring Treatment

Treatment should be initiated for hemangiomas that:

• Involve functionally critical areas (periorbital causing visual obstruction, nasal tip causing airway compromise, lip/mouth causing feeding impairment) 1
• Show ulceration (5-21% incidence), which causes pain, bleeding, infection, and invariable scarring 1
• Are segmental on extremities (higher ulceration risk and permanent skin changes) 1
• Are located in cosmetically sensitive areas with risk of permanent disfigurement 1

First-Line Treatment: Oral Propranolol

For high-risk infantile hemangiomas requiring intervention, oral β-blocker therapy (propranolol) represents the current standard of care, having replaced oral corticosteroids due to greater efficacy and lower toxicity. 1

• Optimal timing for treatment initiation is 1 month of age, during the accelerated growth phase between 5-7 weeks 1
• Hemangioma specialists should evaluate high-risk lesions as soon as possible to facilitate timely intervention 1

Alternative and Adjunctive Treatments

• Pulsed dye laser (PDL) therapy showed significantly greater complete clearance at one year compared to observation (RR 6.10,95% CI 1.89-19.64), though it increased risk of atrophy and hypopigmentation 3
• Oral prednisolone demonstrated significantly greater size reduction compared to intravenous methylprednisolone at three months and one year 3
• For low-risk, small lesions on the torso, observation with the "wait and see" approach remains appropriate 1

Critical Pitfalls to Avoid

• Do not delay referral to a hemangioma specialist for high-risk lesions—the optimal treatment window is narrow, with peak growth occurring at 5-7 weeks of age 1
• Do not assume all hemangiomas will involute without consequence—permanent disfigurement occurs in the majority of untreated cases in referral populations 1
• Do not confuse sinonasal "strawberry skin" appearance with infantile hemangiomas—these are entirely different conditions requiring different specialists 1