An erythematous plaque on the nose: What is your diagnosis?

Abstract

A 55-year-old male presented to our dermatology department with 3 months history of an asymptomatic and red raised plaque on the nose. There was no history of discoloration of skin prior to the development of this lesion. His only medical history was type 2 diabetes and high blood pressure. He had never undergone radiation therapy. On clinical examination, a well-defined glistening bluish-erythematous plaque 3 * 3 cm was present on the nose which was soft and non-tender (Fig. 1). Nasal mucosa was completely spared. No cervical lymphadenopathy was found. Head and neck examination was unremarkable. A CT scan of head and neck founded a soft tissue mass without infiltration of underlying structures. Figure 1: A well-defined glistening bluish-erythematous plaque 3*3 cm on the nose. DERMOSCOPY FINDINGS The dermoscopy revealed homogeneous pattern with combinations of colors (pinkish, bluish, and violaceous) and whitish veil areas without well-defined vessels or lacunae (Fig. 2). Figure 2: Homogeneous pattern with combinations of colors (pinkish, bluish, and violaceous) and whitish veil areas. HISTOLPATHOLOGY The histological examination of the first biopsy revealed a benign fibtoblastic reaction around normal vessels with fibrin deposits and without nuclear atypia. The second skin biopsy showed anastomosing vascular structures of variable diameter in the dermis, lined by plump endothelial cells with marked cellular, nuclear polymorphism and occasional mitosis, dissecting the collagen bundles (Fig. 3a). On immunohistochemistry, tumor cells expressed CD31, ERG, CD34 and VIII Factor. Ki67 was high in tumor cells (60%) (Fig. 3b). Figure 3: (a) HE x 400. Vascular proliferation with atypical endothelial cells (arrow). (b) IHC x 200, Elevated proliferation index Ki67.