When to refer

Cherry angiomas are benign and overwhelmingly straightforward to identify. But certain scenarios warrant caution.

When the lacunar pattern is absent

If a red or purple nodule does not show clear lacunar architecture, do not assume it is a cherry angioma. The absence of lacunae in a vascular-appearing lesion should prompt further evaluation. This is especially important for raised or nodular lesions — nodular amelanotic melanoma can present as a featureless pink-red lump.

When the lesion is changing rapidly

Cherry angiomas grow slowly over months to years. A red lesion that has appeared quickly (days to weeks) or is growing rapidly does not behave like a cherry angioma, regardless of its colour. Rapid growth warrants evaluation.

When the lesion bleeds easily or repeatedly

While cherry angiomas can bleed if traumatised, spontaneous or easy bleeding from a red lesion raises the possibility of pyogenic granuloma or, less commonly, an amelanotic malignancy. If a patient reports that a lesion bleeds repeatedly with minimal provocation, evaluate carefully.

When the pattern is mixed

A lesion that shows lacunae in one area but irregular vessels, pigmentation, or structureless zones in another area does not fit the cherry angioma pattern. Mixed patterns deserve further assessment.