A 23-year-old male presented with a lesion on his left lower extremity. The patient stated the lesion appeared around age 12 as a small dark mole. The lesion continued to grow in size over time and was complicated by pain and occasional bleeding with trauma.
Figure 1. Verrucous hemangiomas usually appear unilaterally on a lower extremity as well-defined, bluish-red, compressible lesions.
Figure 2. A 23-year-old male presented with a lesion on his left lower extremity. An initial biopsy with shave technique was performed and showed features of lymphangioma at initial histopathologic examination.
WHAT IS YOUR DIAGNOSIS?
Diagnosis: Verrucous Hemangioma
Though Halter originated the name verrucous hemangioma in 1937, it was not described in detail until 1967, when Imperial et al defined it as a structural variant of a capillary or cavernous hemangioma in which reactive epidermal acanthosis, papillomatosis and hyperkeratosis develop secondarily.1,2
Clinically, verrucous hemangiomas usually appear unilaterally on a lower extremity as well-defined, bluish-red, compressible lesions (Figure 1 and 2).3,4 They are typically 4 cm-7 cm solitary or grouped lesions, but can take on a linear distribution and have occasionally been observed on the upper extremities as well. These lesions are vascular malformations involving the dermis and subcutaneous tissue that, in the process of spreading, may develop satellite nodules that give the lesion its distinctive warty appearance.2
Histologically, abnormally dilated, thick-walled vessels can be observed in the dermis and may be the result of varied hemodynamics that led to canalization of pre-existing malformed vessels.2,5,6 The vessels in these lesions are CD34 positive and D2-40 negative. This increase in dermal blood supply and the subcutaneous component of verrucous hemangiomas are major contributing factors to the relapse and common recurrence of these lesions after treatment.2
Verrucous hemangiomas are rare and usually develop congenitally or early in childhood, and display a gradual increase in size and number with time.4,5 However, as seen in this case, verrucous hemangiomas can also develop later in life. A concomitant association with Klippel-Trénauny syndrome has been seen in occasional cases of verrucous hemangioma.3
Differential Diagnosis
The differential diagnosis of verrucous hemangiomas includes angiokeratoma, angiokeratoma circumscriptum, Cobb syndrome, angioma serpiginosum, lymphangioma circumscriptum, verrucae, pigmented tumor, capillary-venous malformation and capillary-lymphatic malformation.4,6
Historically, verrucous hemangioma, angiokeratoma circumscripta (solitary hemangioma) and angiokeratoma are often used interchangeably. However, due to differences in histology, clinical behavior and treatment recommendations, it is important to distinguish between these entities.6 In contrast to verrucous hemangiomas, angiokeratomas are telangiectatic lesions that involve only the papillary dermis.2
Treatment
Because they do not resolve spontaneously, early diagnosis and treatment is necessary to prevent relapse and assure a good cosmetic result.4 Due to their expansion into the subcutaneous tissue, deep surgical excision is the treatment of choice for larger lesions, and recurrence becomes problematic in cases of incomplete excision.4,5 In smaller lesions, the risk of recurrence is limited and numerous other treatment options, such as cryosurgery, electrocautery and laser therapy can be considered.4
Yang et al performed a study assessing the efficacy of a combined approach therapy involving surgical excision and laser therapy. The patients participating in this study had lesions with hemangioma-like components in the subcutaneous tissue and dilated subepidermal vascular blood cysts, but there was some variability in size and number of lesions present. The researchers concluded that smaller lesions were cured with one session of surgical therapy, but more extensive lesions required combination therapy of surgical excision followed by CO2, pulsed dye or argon laser therapy for recurrence. Necessary treatment of the subcutaneous component of the verrucous hemangioma was the basis for the development of the combined therapy approach.7
Our Patient
An initial biopsy with shave technique was performed and showed features of lymphangioma at initial histopathologic examination. The lesion was then completely excised with conservative margins and histopathologic examination of the excision specimen showed features consistent with verrucous hemangioma, including epidermal hyperplasia, dilated vascular spaces in the dermis with positive staining of vascular spaces with CD34 and absence of staining with D2-40.
At the most recent follow-up visit, approximately 3 months after complete excision of the lesion, the surgical site had completely healed and the patient remained recurrence free.
Conclusion
Verrucous hemangioma is an uncommon vascular tumor characterized as a solitary blue-black compressible nodule with a verrucous surface on the lower extremity.
The histopathologic characteristics of verrucous hemangiomas are distinguished by epidermal hyperplasia, abnormally dilated, thick-walled vessels in the dermis and subcutis that are CD34 positive and D2-40 negative. The clinical presentation of verrucous hemangiomas and angiokeratomas are similar and histologic examination is needed to differentiate these lesions to provide appropriate treatment and prognostic recommendations.
Multiple treatment options exist. However, lesion recurrence can occur if deep dermal or subcutaneous vessels are not completely removed or destroyed.
Maria Walline is a medical student at New York Medical College in Valhalla, NY.
Jennifer Leininger Nicholson is a dermatology resident at New York Medical College in Valhalla, NY.
William Rietkerk, is assistant attending of dermatology in the Department of Dermatology at New York Medical College in Valhalla, NY.
Disclosure: The authors have no conflicts of interest to report.
References
1. Halter K. Hemangioma verrucosum mit osteoatrophie. Dermatol Z. 1937;75(5):275-279.
2. Imperial R, Helwig EB. Verrucous hemangioma. A clinicopathologic study of 21 cases. Arch Dermatol. 1967;96(3):247-253.
3. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2006.
4. Koc M, Kavala M, Kocatürk E, et al. An unusual vascular tumor: verrucous hemangioma. Dermatol Online J. 2009;15(11):7.
5. Kaliyadan F, Dharmaratnam AD, Jayasree MG, Sreekanth G. Linear verrucous hemangioma. Dermatol Online J. 2009;15(5):15.
6. Tennant LB, Mulliken JB, Perez-Atayde AR, Kozakewich HP. Verrucous hemangioma revisited. Pediatr Dermatol. 2006;23(3):208-215.
7. Yang CH, Ohara K. Successful surgical treatment of verrucous hemangioma: a combined approach. Dermatol Surg. 2002;28(10):913-920.
A 23-year-old male presented with a lesion on his left lower extremity. The patient stated the lesion appeared around age 12 as a small dark mole. The lesion continued to grow in size over time and was complicated by pain and occasional bleeding with trauma.
Figure 1. Verrucous hemangiomas usually appear unilaterally on a lower extremity as well-defined, bluish-red, compressible lesions.
Figure 2. A 23-year-old male presented with a lesion on his left lower extremity. An initial biopsy with shave technique was performed and showed features of lymphangioma at initial histopathologic examination.
WHAT IS YOUR DIAGNOSIS?
Diagnosis: Verrucous Hemangioma
Though Halter originated the name verrucous hemangioma in 1937, it was not described in detail until 1967, when Imperial et al defined it as a structural variant of a capillary or cavernous hemangioma in which reactive epidermal acanthosis, papillomatosis and hyperkeratosis develop secondarily.1,2
Clinically, verrucous hemangiomas usually appear unilaterally on a lower extremity as well-defined, bluish-red, compressible lesions (Figure 1 and 2).3,4 They are typically 4 cm-7 cm solitary or grouped lesions, but can take on a linear distribution and have occasionally been observed on the upper extremities as well. These lesions are vascular malformations involving the dermis and subcutaneous tissue that, in the process of spreading, may develop satellite nodules that give the lesion its distinctive warty appearance.2
Histologically, abnormally dilated, thick-walled vessels can be observed in the dermis and may be the result of varied hemodynamics that led to canalization of pre-existing malformed vessels.2,5,6 The vessels in these lesions are CD34 positive and D2-40 negative. This increase in dermal blood supply and the subcutaneous component of verrucous hemangiomas are major contributing factors to the relapse and common recurrence of these lesions after treatment.2
Verrucous hemangiomas are rare and usually develop congenitally or early in childhood, and display a gradual increase in size and number with time.4,5 However, as seen in this case, verrucous hemangiomas can also develop later in life. A concomitant association with Klippel-Trénauny syndrome has been seen in occasional cases of verrucous hemangioma.3
Differential Diagnosis
The differential diagnosis of verrucous hemangiomas includes angiokeratoma, angiokeratoma circumscriptum, Cobb syndrome, angioma serpiginosum, lymphangioma circumscriptum, verrucae, pigmented tumor, capillary-venous malformation and capillary-lymphatic malformation.4,6
Historically, verrucous hemangioma, angiokeratoma circumscripta (solitary hemangioma) and angiokeratoma are often used interchangeably. However, due to differences in histology, clinical behavior and treatment recommendations, it is important to distinguish between these entities.6 In contrast to verrucous hemangiomas, angiokeratomas are telangiectatic lesions that involve only the papillary dermis.2
Treatment
Because they do not resolve spontaneously, early diagnosis and treatment is necessary to prevent relapse and assure a good cosmetic result.4 Due to their expansion into the subcutaneous tissue, deep surgical excision is the treatment of choice for larger lesions, and recurrence becomes problematic in cases of incomplete excision.4,5 In smaller lesions, the risk of recurrence is limited and numerous other treatment options, such as cryosurgery, electrocautery and laser therapy can be considered.4
Yang et al performed a study assessing the efficacy of a combined approach therapy involving surgical excision and laser therapy. The patients participating in this study had lesions with hemangioma-like components in the subcutaneous tissue and dilated subepidermal vascular blood cysts, but there was some variability in size and number of lesions present. The researchers concluded that smaller lesions were cured with one session of surgical therapy, but more extensive lesions required combination therapy of surgical excision followed by CO2, pulsed dye or argon laser therapy for recurrence. Necessary treatment of the subcutaneous component of the verrucous hemangioma was the basis for the development of the combined therapy approach.7
Our Patient
An initial biopsy with shave technique was performed and showed features of lymphangioma at initial histopathologic examination. The lesion was then completely excised with conservative margins and histopathologic examination of the excision specimen showed features consistent with verrucous hemangioma, including epidermal hyperplasia, dilated vascular spaces in the dermis with positive staining of vascular spaces with CD34 and absence of staining with D2-40.
At the most recent follow-up visit, approximately 3 months after complete excision of the lesion, the surgical site had completely healed and the patient remained recurrence free.
Conclusion
Verrucous hemangioma is an uncommon vascular tumor characterized as a solitary blue-black compressible nodule with a verrucous surface on the lower extremity.
The histopathologic characteristics of verrucous hemangiomas are distinguished by epidermal hyperplasia, abnormally dilated, thick-walled vessels in the dermis and subcutis that are CD34 positive and D2-40 negative. The clinical presentation of verrucous hemangiomas and angiokeratomas are similar and histologic examination is needed to differentiate these lesions to provide appropriate treatment and prognostic recommendations.
Multiple treatment options exist. However, lesion recurrence can occur if deep dermal or subcutaneous vessels are not completely removed or destroyed.
Maria Walline is a medical student at New York Medical College in Valhalla, NY.
Jennifer Leininger Nicholson is a dermatology resident at New York Medical College in Valhalla, NY.
William Rietkerk, is assistant attending of dermatology in the Department of Dermatology at New York Medical College in Valhalla, NY.
Disclosure: The authors have no conflicts of interest to report.
References
1. Halter K. Hemangioma verrucosum mit osteoatrophie. Dermatol Z. 1937;75(5):275-279.
2. Imperial R, Helwig EB. Verrucous hemangioma. A clinicopathologic study of 21 cases. Arch Dermatol. 1967;96(3):247-253.
3. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2006.
4. Koc M, Kavala M, Kocatürk E, et al. An unusual vascular tumor: verrucous hemangioma. Dermatol Online J. 2009;15(11):7.
5. Kaliyadan F, Dharmaratnam AD, Jayasree MG, Sreekanth G. Linear verrucous hemangioma. Dermatol Online J. 2009;15(5):15.
6. Tennant LB, Mulliken JB, Perez-Atayde AR, Kozakewich HP. Verrucous hemangioma revisited. Pediatr Dermatol. 2006;23(3):208-215.
7. Yang CH, Ohara K. Successful surgical treatment of verrucous hemangioma: a combined approach. Dermatol Surg. 2002;28(10):913-920.
A 23-year-old male presented with a lesion on his left lower extremity. The patient stated the lesion appeared around age 12 as a small dark mole. The lesion continued to grow in size over time and was complicated by pain and occasional bleeding with trauma.
Figure 1. Verrucous hemangiomas usually appear unilaterally on a lower extremity as well-defined, bluish-red, compressible lesions.
Figure 2. A 23-year-old male presented with a lesion on his left lower extremity. An initial biopsy with shave technique was performed and showed features of lymphangioma at initial histopathologic examination.
WHAT IS YOUR DIAGNOSIS?
Diagnosis: Verrucous Hemangioma
Though Halter originated the name verrucous hemangioma in 1937, it was not described in detail until 1967, when Imperial et al defined it as a structural variant of a capillary or cavernous hemangioma in which reactive epidermal acanthosis, papillomatosis and hyperkeratosis develop secondarily.1,2
Clinically, verrucous hemangiomas usually appear unilaterally on a lower extremity as well-defined, bluish-red, compressible lesions (Figure 1 and 2).3,4 They are typically 4 cm-7 cm solitary or grouped lesions, but can take on a linear distribution and have occasionally been observed on the upper extremities as well. These lesions are vascular malformations involving the dermis and subcutaneous tissue that, in the process of spreading, may develop satellite nodules that give the lesion its distinctive warty appearance.2
Histologically, abnormally dilated, thick-walled vessels can be observed in the dermis and may be the result of varied hemodynamics that led to canalization of pre-existing malformed vessels.2,5,6 The vessels in these lesions are CD34 positive and D2-40 negative. This increase in dermal blood supply and the subcutaneous component of verrucous hemangiomas are major contributing factors to the relapse and common recurrence of these lesions after treatment.2
Verrucous hemangiomas are rare and usually develop congenitally or early in childhood, and display a gradual increase in size and number with time.4,5 However, as seen in this case, verrucous hemangiomas can also develop later in life. A concomitant association with Klippel-Trénauny syndrome has been seen in occasional cases of verrucous hemangioma.3
Differential Diagnosis
The differential diagnosis of verrucous hemangiomas includes angiokeratoma, angiokeratoma circumscriptum, Cobb syndrome, angioma serpiginosum, lymphangioma circumscriptum, verrucae, pigmented tumor, capillary-venous malformation and capillary-lymphatic malformation.4,6
Historically, verrucous hemangioma, angiokeratoma circumscripta (solitary hemangioma) and angiokeratoma are often used interchangeably. However, due to differences in histology, clinical behavior and treatment recommendations, it is important to distinguish between these entities.6 In contrast to verrucous hemangiomas, angiokeratomas are telangiectatic lesions that involve only the papillary dermis.2
Treatment
Because they do not resolve spontaneously, early diagnosis and treatment is necessary to prevent relapse and assure a good cosmetic result.4 Due to their expansion into the subcutaneous tissue, deep surgical excision is the treatment of choice for larger lesions, and recurrence becomes problematic in cases of incomplete excision.4,5 In smaller lesions, the risk of recurrence is limited and numerous other treatment options, such as cryosurgery, electrocautery and laser therapy can be considered.4
Yang et al performed a study assessing the efficacy of a combined approach therapy involving surgical excision and laser therapy. The patients participating in this study had lesions with hemangioma-like components in the subcutaneous tissue and dilated subepidermal vascular blood cysts, but there was some variability in size and number of lesions present. The researchers concluded that smaller lesions were cured with one session of surgical therapy, but more extensive lesions required combination therapy of surgical excision followed by CO2, pulsed dye or argon laser therapy for recurrence. Necessary treatment of the subcutaneous component of the verrucous hemangioma was the basis for the development of the combined therapy approach.7
Our Patient
An initial biopsy with shave technique was performed and showed features of lymphangioma at initial histopathologic examination. The lesion was then completely excised with conservative margins and histopathologic examination of the excision specimen showed features consistent with verrucous hemangioma, including epidermal hyperplasia, dilated vascular spaces in the dermis with positive staining of vascular spaces with CD34 and absence of staining with D2-40.
At the most recent follow-up visit, approximately 3 months after complete excision of the lesion, the surgical site had completely healed and the patient remained recurrence free.
Conclusion
Verrucous hemangioma is an uncommon vascular tumor characterized as a solitary blue-black compressible nodule with a verrucous surface on the lower extremity.
The histopathologic characteristics of verrucous hemangiomas are distinguished by epidermal hyperplasia, abnormally dilated, thick-walled vessels in the dermis and subcutis that are CD34 positive and D2-40 negative. The clinical presentation of verrucous hemangiomas and angiokeratomas are similar and histologic examination is needed to differentiate these lesions to provide appropriate treatment and prognostic recommendations.
Multiple treatment options exist. However, lesion recurrence can occur if deep dermal or subcutaneous vessels are not completely removed or destroyed.
Maria Walline is a medical student at New York Medical College in Valhalla, NY.
Jennifer Leininger Nicholson is a dermatology resident at New York Medical College in Valhalla, NY.
William Rietkerk, is assistant attending of dermatology in the Department of Dermatology at New York Medical College in Valhalla, NY.
Disclosure: The authors have no conflicts of interest to report.
References
1. Halter K. Hemangioma verrucosum mit osteoatrophie. Dermatol Z. 1937;75(5):275-279.
2. Imperial R, Helwig EB. Verrucous hemangioma. A clinicopathologic study of 21 cases. Arch Dermatol. 1967;96(3):247-253.
3. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2006.
4. Koc M, Kavala M, Kocatürk E, et al. An unusual vascular tumor: verrucous hemangioma. Dermatol Online J. 2009;15(11):7.
5. Kaliyadan F, Dharmaratnam AD, Jayasree MG, Sreekanth G. Linear verrucous hemangioma. Dermatol Online J. 2009;15(5):15.
6. Tennant LB, Mulliken JB, Perez-Atayde AR, Kozakewich HP. Verrucous hemangioma revisited. Pediatr Dermatol. 2006;23(3):208-215.
7. Yang CH, Ohara K. Successful surgical treatment of verrucous hemangioma: a combined approach. Dermatol Surg. 2002;28(10):913-920.
