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CORRESPONDENCE
Year : 2011  |  Volume : 56  |  Issue : 5  |  Page : 599-600
Verrucous hemangioma or angiokeratoma? A missed diagnosis


1 Derma-care, Skin & Cosmetology Center, Mangalore, India
2 Department of Obstetrics and Gynaecology, The K S Hegde Medical Academy, Mangalore, India
3 Department of Pathology, Kasturba Medical College, Mangalore, India
4 Derma-care, Skin and Cosmetology Centre, Mangalore, India

Date of Web Publication4-Nov-2011

Correspondence Address:
S Pavithra
Derma-care, Skin & Cosmetology Center, Mangalore
India
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DOI: 10.4103/0019-5154.87171

PMID: 22121293

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How to cite this article:
Pavithra S, Mallya H, Kini H, Pai G S. Verrucous hemangioma or angiokeratoma? A missed diagnosis. Indian J Dermatol 2011;56:599-600

How to cite this URL:
Pavithra S, Mallya H, Kini H, Pai G S. Verrucous hemangioma or angiokeratoma? A missed diagnosis. Indian J Dermatol [serial online] 2011 [cited 2014 Apr 18];56:599-600. Available from: http://www.e-ijd.org/text.asp?2011/56/5/599/87171


Sir,

A 14-year-old girl presented with an exuberant warty brownish growth on her right great toe. A history revealed that when she was 4 years old, she had a small similar lesion, a part of which was biopsied by a general surgeon and was reported as angiokeratoma.

Examination revealed a solitary hyperpigmented, hyperkeratoic plaque consisting of closely set warty papules measuring 3 cm × 3.5 cm involving the pulp space of the right great toe. Surface of the lesion was firm and verrucous with no ulceration, bleeding or atrophy [Figure 1]. The lesion was non-compressible and diascopy was negative. Regional lymph nodes were not enlarged. Systemic examination was normal. Routine laboratory investigations and X-ray chest were also found to be normal.
Figure 1: Solitary hyperpigmented, hyperkeratoic verrucous plaque consisting of closely set warty papules measuring 3 cm × 3.5 cm involving the pulp space of the right great toe

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The patient was then considered for surgery. A wide local excision of the lesion was done and the defect was closed by an islanded plantar digital artery flap in a V-Y fashion adjacent and just prominal to the excision wound. The excised specimen was sent for histopathological examination. We considered a clinical diagnosis of tuberculosis verrucosa cutis and angiokeratoma.

Hematoxylin and eosin stained section of the specimen showed marked hyperkeratosis, parakeratosis, papillomatosis, and elongation of the rete ridges. To our surprise, it extended from the derma-epidermal junction into the deeper dermis, where numerous small to large vascular channels were seen lined by flattened endothelial cells and filled with blood. Intervening dermal fibrosis and chronic inflammatory infiltrate was also present [Figure 2]. This is not a finding of angiokeratoma as it involves only the papillary dermis without any extension to the deep dermis and the subcutaneous fat.
Figure 2: Papillomatosis and elongation of the rete ridges are seen. Extending from the dermo-epidermal junction into the deeper dermis, vascular channels are seen lined by flattened endothelial cells and filled with blood (Hematoxylin and eosin stain, ×20)

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Based on this clear histopathological evidence, a correct diagnosis of verrcuous hemangioma was made which had earlier been interpreted as angiokeratoma on superficial biopsy.

Verrucous hemangioma is a rare variety of angiomatous nevi usually involving the lower extremities. [1] Lesions are mostly seen at birth or appear during childhood. Initially, they are soft, bluish-red vascular lesion, but with time they enlarge and develop keratotic and verrucous features. [2]

Clinically verrucous hemangioma simulates angiokeratoma, but histopathologically they can be clearly differentiated as the former involves the dermis and subcutaneous fat and the latter involves only the papillary dermis. [1]

This differentiation is important for the management of the lesion as complete excision and grafting is indicated in verrucous hemangioma. [3] Incomplete excision would lead to recurrence of the lesion because of the deeper components. [4]

Thus, it is now evident that the biopsy of the lesion, which was done when the child was 4 years old was superficial. In turn, this has lead to an error in the histopathological diagnosis and a recurrence of growth.

 
   References Top

1.Imperial R, Helwig EB. Verrucous Hemangioma- A clinicopathologic study of 21 cases. Arch Dermatol 1967; 96:247-53.  Back to cited text no. 1
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2.Loria PR, Derbes VJ, Krafchuk JD. Keratotic haemangioma. Arch Dermatol 1958;77:216-9.  Back to cited text no. 2
    
3.Mani MZ, Feierabend TC. Verucous Hemangioma, Report of a case treated by skin grafting. Ind J Dermatol Venereol Leprol 1982;48:116-7.  Back to cited text no. 3
    
4.Caro WA. Tumours of the skin. In: Moschella SL, Pillsbury DM, Hurley HJ, editors. Textbook of Dermatology. 1 st ed. Philadelphia: WB Saunders; 1975. p. 1383.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]

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