A case of verrucous hemangioma and its dermoscopic features.

Abstract

Sir, Verrucous hemangioma is a congenital, vascular lesion characterized by a gradual, progressive development of hyperkeratosis on the surface. Rarely the lesions may present for the first time in childhood and adulthood. The lesions usually present as solitary hyperkeratotic, bluish, and partly confluent lesions. A 20-year-old male patient presented with purplish skin lesions restricted to the left lower limb. The lesions had been present since birth and there was a history of occasional bleeding from the lesions especially after trauma. The lesions had gradually increased in size and number and many of the lesions developed scaling on the surface. On examination multiple lesions were seen restricted to the left lower limb. While most of the lesions were purplish nodules, some of them had significant hyperkeratosis over the surface [Figures ​[Figures11–3]. There was no difference in limb girth between the limbs. No other significant skin or mucosal lesions were noted. Figure 1 Verrucous hemangioma lesions in different stages of evolution Figure 3 Close up of early hemangiomatous lesions Figure 2 Verrucous hemangioma lesions in different stages of evaluation—early flat lesions and evolved hyperkeratotic lesions The dermoscopic features were different depending on the type and area of the lesions. The most striking feature was a prominent bluish shade with many areas showing an appearance of a blue-white veil. Hyperkeratosis was observed in most lesions but was the dominant feature in the verrucous lesions. The periphery of the lesions showed well-defined dark blue lacunae characteristic of vascular lesions [Figures ​[Figures44–7]. Figure 4 Dermoscopy of relatively early lesions of verrucous hemangioma showing a prominent bluish white hue similar to a blue-white veil in some areas, indicating the hyperkeratosis over the underlying vascular channels, which is seen in the histopathology Figure 7 Peripheral areas of the lesion showing the dark blue lacunae characteristic of vascular lesions correlating with the vascular channels seen in histopathology Figure 5 Dermoscopy of the late lesions showing the more prominent hyperkeratosis along with the bluish lacunae indicating the underlying dilated vascular channels Figure 6 Dermoscopy showing very prominent hyperkeratosis in the fully developed lesions Biopsy from one of the lesions showed hyperkeratosis, acanthosis, papillomatous and proliferation in the epidermis. Multiple vascular channels were seen extending from the papillary dermis to the deep dermis. The histopathological appearance was suggestive of verrucous hemangioma. The location of the dilated vascular channels in the deeper dermis ruled out other possibilities such as angiokeratoma circumscriptum naeviforme [Figure 8]. Figure 8 Histopathology H and E ×20 showing hyperkeratosis, acanthosis, and multiple vascular channels in the dermis The patient was referred to reconstructive surgery for excision of the lesions. All the lesions were excised with a 1 cm margin, under tourniquet control. The smaller lesions were closed primarily while the larger lesions were covered with a skin graft. Verrucous hemangioma typically presents as solitary and localized lesions present since birth.[1,2] To the best of our knowledge, there is only one report demonstrating the dermoscopic features in verrucous hemangioma. Popadic reported the case of a solitary verrucous hemangioma over the right leg. The main dermoscopic features in the case reported by Popadic included an alveolar appearance with numerous small, oval to polygonal elements surrounded by slightly darker pigmentation. Popadic described different shades of blue, including light blue, indigo blue, and dark bluish-black and a blue-white veil. Well-defined dark lacunae were seen in the periphery. The same case described by Popadic on follow up became a dark bluish-black, raised nodule, with irregular borders and hyperkeratotic surface, and dermoscopic examination showed a more marked alveolar appearance, with more pronounced sulci. There was a dominant bluish color to the lesion.[3,4] In our case we could not find a significant alveolar pattern, but all the other features were seen. The main highlight in our case was the expected dominant hyperkeratosis seen in the verrucous lesions. The treatment of choice for verrucous hemangiomas is surgical excision, the general concept being that smaller lesions are excised in a single sitting, whereas larger lesions require multiple sessions with or without combination treatment using other modalities. Various other options that have been tried with limited results include ultrasound, lasers, and cryotherapy.[1,2,5] This particular case was interesting not only because of its rarity, but also the presence of both verrucous and preverrucous stages in the same patient and the characteristically different dermoscopic patterns in both types of lesions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.