A 4-month-old girl presented to the pediatric dermatology clinic due to an enlarging growth on the abdomen. The child was born to a 32-year-old G8P6 woman via spontaneous vaginal delivery at 39 weeks and 5 days. Her mother identifies as South Sudanese. She received all recommended prenatal care. Pregnancy was complicated by low weight gain and cerclage placement. Delivery was complicated by meconium-stained amniotic fluid but otherwise uneventful and APGARS was 8,9. Newborn skin examination was completely normal, and her 2-week-old well check was also unremarkable. At her next appointment (5 weeks of age), a new skin growth was noted on the right abdomen. There was no ulceration or bleeding, and the growth did not appear to be bothersome to the infant. The plaque continued to enlarge, and she was referred to the pediatric dermatology clinic. On examination, there was a solitary 0.8 × 1.0 cm dark brown plaque with slight pink hue at the edges (Figure 1). Dermoscopy was performed (Figure 2). Dermoscopy showed mainly red lacunae with white septa consistent with an infantile hemangioma. This case underscores the utility of dermoscopy in diagnosing vascular growths such as infantile hemangioma (IH) in more deeply pigmented skin. In darker skin types, diagnosis of vascular lesions on general examination is made more challenging by the presence of melanin in the epidermis. Dermoscopy allows for enhanced visualization of structures below the stratum corneum to the level of the superficial dermis and allows for more accurate diagnosis of both melanocytic and non-melanocytic lesions.1 To date, the utility of dermoscopy in diagnosing vascular lesions in skin of color has not been well described. In both lighter and darker phototypes, the primary dermoscopic feature of the hemangioma is the red lacuna (lake of blood), usually separated by pale septae.2 In darker phototypes, dermoscopy may be particularly useful in distinguishing these red lacunae from brown globules (which are seen in melanocytic lesions), and from red structureless areas with white collarettes (which are seen in pyogenic granulomas).1 Dermoscopy of superficial port wine stain can show a uniform “lawn” of dotted and occasionally tortuous vessels, sometimes with an overlying gray-white veil if there is a deeper component.3 In some cases, the color of lacunae on dermoscopy may help clarify the depth of the lesion (superficial IHs tend to have bright red lacunae, while the lacunae of deeper IHs may have a more blue or violaceous hue). However, melanin can impart a blue hue; thus, one must take into consideration the patient's phototype and other clinical clues (ie, nodularity and height) when assessing depth.1 Serial dermoscopic examination can also help to identify subtle changes in hemangiomas; a superficial white cast portending ulceration can often be more easily appreciated with a dermatoscope.4 Infantile hemangioma is more commonly diagnosed in Caucasians compared with other ethnicities, and girls are more commonly affected than boys.5 Prematurity also appears to be a significant contributing risk factor.5 In one retrospective analysis of the National Hospital Discharge Survey, a doubling of IH incidence rate was observed in White infants between 1976 and 2006, thought to be explained at least partly by increasing rates of low birth weight births in White people in that time period.6 Infantile hemangioma is an uncommon diagnosis in neonates of African descent, for reasons that have not been fully clarified. One hypothesis for this variation by ethnic background is the protein fibromodulin, which is secreted by melanocytes. Though individuals with darker skin do not have increased melanocyte number per unit skin area, they may produce more fibromodulin, which has been identified as a key regulator of angiogenesis.7 Speculatively, the activity of fibromodulin could partly account for the decreased incidence of diseases of vascular proliferation in individuals of African descent, which include both IH and age-related macular degeneration.8 One report identified three African American infants with segmental IHs requiring systemic therapy with propranolol. All three cases were associated with hypertension (an association that has not otherwise been reported with IHs), and two of the three infants experienced improvement in blood pressure with propranolol therapy. All three infants otherwise responded well to propranolol therapy with regards to their hemangiomas. The full significance of these findings is unknown due to the rarity of segmental hemangiomas in infants of African descent. In conclusion, IHs are less common in phototype IV, V, and VI skin, but do occur. Dermoscopy can facilitate rapid and accurate diagnosis and ensure timely intervention when indicated.
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