Question: My two-year-old daughter has a small lump on the front of her hand. She had what looked like an insect bite a week or so ago, but now it looks like a thorn may be stuck in her skin. It looks to be quite deep and wouldn't be easy to get out. It isn't inflamed and she says it doesn't hurt. What should I do? My instinct is to leave it alone as it isn't bothering her and doesn't look red or infected.
Answer: Often the devil is in the detail when it comes to trying to work out what exactly might have got stuck in her hand (if anything). At the time of the incident, she clearly wasn't upset as she didn't present to you complaining of pain. You probably noticed a small mark on her skin putting her to bed that evening. At two years of age, she is too young to be able to tell you what happened earlier that day. But if she was playing near a wooden structure or rose bushes, then there is a possibility she was injured by a splinter or thorn.
Next you should consider the exact site of the injury. If the skin lesion is near the fingertip or pulp, then it's more likely be a residual foreign body like a splinter or thorn. Conversely, it's more likely to be an insect bite on the dorsum or back (posterior surface) of the hand. I know you said 'front' of her hand, but the anatomical position of the human body is similar to the Vitruvian Man by DaVinci with the palms of the hand pointing forward/outward, making the palms the anterior surface.
You seem to think she had an insect bite about one week prior to the soft-tissue swelling.
It could be a retained stinger from a bee sting. If so, at this stage one week after the initial injury, the soft-tissue swelling may be a sign of local skin infection. However, a local skin infection should cause pain and redness and thankfully this does not apply to your daughter.
It could be your daughter's immune reaction to the saliva from an arthropod (insect) that is causing the localised swelling. The insect's saliva contains concentrated irritant substances such as anticoagulants, digestive enzymes (e.g. amylases and esterases), agglutinins, and mucopolysaccharides.
In general, this secondary delayed skin reaction is associated with local swelling, itching, and redness. Once again, from what you describe, your daughter does not have any itching or redness. Uncommonly, these localised skin reactions can evolve into vesicular, bullous or necrotic looking skin lesions due to venom from certain spider or centipede bites.
The thought of a possible retained thorn or splinter has obviously crossed your mind. There is a risk of causing further trauma to the skin (and the child) by attempting to remove it. She may tolerate you having a close look at it, but will not like any one tampering with it. Good light and ideally a magnifying glass would make the inspection a little easier. Most toddlers are unlikely to comply with a doctor or nurse putting a tweezers to her skin for very long.
There is a saying in paediatric medicine that you should 'always listen to the mother'. In other words, you know your daughter best and your maternal instinct is telling you to leave well enough alone for now. I suggest you continue to monitor it daily for signs of redness, itching and scratch marks. It's easy to demarcate the lesion by drawing a circle around the lesion with a black marker. This helps to determine if it is enlarging or not. Ideally you should take daily pictures of your daughter's skin lesion. If it is enlarging or causing her any discomfort, then you need to have a doctor examine it. I suspect over time it will either resolve spontaneously, or you will see the tiny splinter or thorn come upwards and can grab it yourself with a clean tweezers.
⬤ Dr Jennifer Grant is a GP with the Beacon HealthCheck