|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 99-100
Verrucous hemangioma: Importance of a deeper biopsy
Shricharith Shetty1, V Geetha2, Raghavendra Rao1, Sathish Pai1
1 Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
2 Department of Pathology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||18-Dec-2014|
Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shetty S, Geetha V, Rao R, Pai S. Verrucous hemangioma: Importance of a deeper biopsy. Indian J Dermatopathol Diagn Dermatol 2014;1:99-100
|How to cite this URL:|
Shetty S, Geetha V, Rao R, Pai S. Verrucous hemangioma: Importance of a deeper biopsy. Indian J Dermatopathol Diagn Dermatol [serial online] 2014 [cited 2020 Oct 26];1:99-100. Available from: https://www.ijdpdd.com/text.asp?2014/1/2/99/147319
Verrucous hemangioma is a rare congenital vascular anomaly that presents at birth or in early childhood. It is commonly unilateral and localized to the lower extremities. It presents as a warty, bluish-purple plaque, with intermittent oozing or bleeding. Early on, the lesions are nonkeratotic, soft, and bluish red, but in time they become increasingly hyperkeratotic. Verrucous hemangioma does not involute spontaneously and can persist after incomplete excision.  Often misdiagnosed clinically as angiokeratoma, it is the histopathology that helps to differentiate these two conditions. We herein report a case of verrucous hemangioma localized to the leg, emphasizing the importance of taking a deeper skin biopsy during evaluation.
A 14-year-old male presented with a complaint of a brownish growth over his left foot, since the age of three years. It had enlarged gradually over time and bled after minor trauma, occasionally, although it was not painful. Physical examination revealed a solitary hyperpigmented, verrucous plaque measuring 4 × 7 cm, over the dorsum of the left foot, with surrounding hyperpigmentation [Figure 1]. Part of the lesion was biopsied elsewhere and was reported as angiokeratoma. A repeat biopsy was sought. Adequate tissue sample was obtained by an incisional biopsy for histopathological examination. The biopsy revealed an epidermis showing verruciform proliferation with hyper- and parakeratosis, irregular acanthosis, and papillomatosis. Ectatic dilated channels, some with luminal red blood cells and thrombi were seen in the papillary dermis. The dermis and subcutis showed proliferating thin-walled vascular channels lined by flattened endothelial cells, with a pseudo-infiltrative pattern and focal lobular configuration [Figure 2]. The features were suggestive of verrucous hemangioma. The lesion was surgically excised and a skin graft from the thigh was placed. The patient was followed up for eight months and there was no sign of recurrence.
|Figure 2: (a) Raised hyperkeratotic lesion, with dermis showing congested capillaries. (H and E, ×25) (b)Angiokeratoma-like appearance of the vessels in the papillary dermis. (H and E, ×200) (c) Deep dermal component of verrucous haemangioma. (H and E, ×200) (d) Lobular configuration of the component in the subcutis. (H and E, ×200)|
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In 1937, Halter first used the term 'Verrucous hemangioma' to describe the case of a 16-year-old boy presenting with a linear, purpuric cluster of plaques, extending from the right buttock to the toes.  Imperial and Helwig studied 21 patients with verrucous hemangioma and considered these lesions to be variants of capillary malformations that secondarily develop reactive epidermal acanthosis, hyperkeratosis, and parakeratosis.  It is also known by various other names, including, angiokeratoma circumscriptum naeviforme, angiokeratoma circumscriptum, angiokeratoma corporis naeviforme, and keratotic hemangioma. ,, Thus, verrucous hemangioma has frequently been mistakenly classified as a variety of angiokeratoma. The histological appearance closely resembles an angiokeratoma, as both lesions show vascular spaces just beneath a papillomatosis and hyperkeratotic epidermis.  However, in contrast to angiokeratoma, the vascular spaces in verrucous hemangioma also involve the lower dermis and subcutaneous tissues.  Verrucous hemangiomas show cytoplasmic immunoreactivity for the GLUT1 protein within the endothelial cells, lining the lesional vascular structures, whereas, angiokeratoma are always negative for GLUT1. , In contrast to angiokeratoma, use of cryotherapy, electrocautery, and laser in the treatment of verrucous hemangioma has always resulted in failure to control the disease, and adequate surgical excision is essential to prevent recurrence. Thus, it is of utmost importance to take a deeper skin biopsy with an adequate tissue sample, to differentiate the two closely resembling entities, verrucous hemangioma and angiokeratoma, as the treatment and prognosis varies for both.
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[Figure 1], [Figure 2]