Chapter V.5 Vascular Lesions Fezal Özdemir V.5 Contents V.5.1 Introduction. 303 V.5.5.2 Subcorneal Hematoma. 310 V.5.2 Hemangiomas. 303 V.5.5.2.1 Definition. 310 V.5.2.1 Cherry Hemangioma. 304 V.5.5.2.2 Clinical Features. 310 V.5.2.1.1 Definition. 304 V.5.5.2.3 Dermoscopic Criteria. 310 V.5.2.1.2 Clinical Features. 304 V.5.5.2.4 Relevant Clinical Differential V.5.2.1.3 Dermoscopic Criteria. 304 Diagnoses. 310 V.5.2.1.4 Relevant Clinical Differential V.5.5.2.5 Histopathology. 310 Diagnoses. 304 V.5.5.2.6 Management . 310 V.5.2.1.5 Histopathology. .304 V.5.6 Case Study . 310 V.5.2.1.6 Management . .305 References. 312 V.5.3 Pyogenic Granuloma. 305 V.5.3.1 Definition. 305 V.5.3.2 Clinical Features. 305 V.5.3.3 Dermoscopic Criteria. 305 V.5.1 Introduction V.5.3.4 Relevant Clinical Differential Diagnosis. 306 V.5.3.5 Histopathology. .306 The biological classification of vascular lesions V.5.3.6 Management . .307 into two major categories as tumors and malfor- mations [19] forms a framework for conceiving V.5.4 Angiokeratomas . 307 them in a coherent manner, although evidence V.5.4.1 Solitary Angiokeratoma. 307 for their association has been reported in a small V.5.4.1.1 Definition. 307 minority [9]. Among them, the lesions that V.5.4.1.2 Clinical Features. 307 simulate pigmented skin tumors, especially the V.5.4.1.3 Dermoscopic Criteria. 307 melanoma, are discussed in this chapter. Some V.5.4.1.4 Relevant Clinical Differential of these fall into the category of tumors (hem- Diagnoses. 307 angioma, pyogenic granuloma) and some into V.5.4.1.5 Histopathology. .307 malformations (angiokeratoma). In addition, V.5.4.1.6 Management . .308 subcorneal and subungual hemorrhage is in- V.5.5 Hemorrhages. .308 cluded here for diagnostic purposes. V.5.5.1 Subungual Hematoma. 308 V.5.5.1.1 Definition. 308 V.5.5.1.2 Clinical Features. 308 V.5.2 Hemangiomas V.5.5.1.3 Dermoscopic Criteria. 308 V.5.5.1.4 Histopathology. .308 Hemangiomas are benign vascular tumors V.5.5.1.5 Relevant Clinical Differential due to the proliferation of blood vessels. The Diagnoses. 308 term includes many entities, namely, infantile V.5.5.1.6 Management . .308 hemangiomas (localized, segmental, multifocal, 304 F. Özdemir ­undetermined), congenital hemangiomas (non- involuting, rapidly involuting) [20], cherry hem- angioma, tufted angioma, verrucous hemangio- ma, arteriovenous hemangioma, thrombosed capillary aneurysm, and lobular capillary hem- angioma (pyogenic granuloma). Some of these entities are beyond the scope of this chapter, and some are misnomers, but some will be consid- ered for their unique dermoscopic criteria and resemblance to melanoma. V.5.2.1 Cherry Hemangioma V.5.2.1.1 Definition Cherry hemangiomas (senile angioma, ruby spot, Campbell de Morgan spot) are the most com- mon vascular lesions that appear as small, bright- red papules in adulthood, usually on the trunk. V.5.2.1.2 Clinical Features Cherry hemangiomas vary in size from hardly visible, pinpoint lesions to soft, raised, dome- shaped, bright-red papules with a smooth sur- Fig. V.5.1. a Cherry hemangioma, clinical view. A soft, face measuring several millimeters in diameter polypoid, red-colored papule with a diameter of 4×6 mm (Fig. V.5.1a). The incidence rises sharply in the is shown. b Cherry hemangioma, dermoscopy view. A fourth decade, being almost universal in old typical lacunar pattern with circumscript, round-to-oval red structures, namely, lacunas, is shown age. They develop alone or in groups, several to hundreds in number occurring anywhere on the skin but most commonly on the trunk and proximal extremities [25]. V.5.2.1.4 Relevant Clinical Differential Diagnoses V.5.2.1.3 Dermoscopic Criteria Thrombosed lesions may resemble angiokera- toma or melanoma, which can be differentiated Cherry hemangiomas reveal a typical lacunar by dermoscopy. Pyogenic granuloma differs pattern with red-blue lacunas (or lagoons) [29, with its sudden unset. 34] which are characterized by circumscribed, round-to-oval structures with a color varying from red, red-blue, dark-red to black (Fig. V.5.1b) V.5.2.1.5 Histopathology [2, 16]. Criteria for melanocytic lesions should be absent, which is valid for all vascular lesions Cherry hemangiomas are composed of dilated [3, 30, 34]. Histopathologically, red lacunas rep- capillaries and scant intervening stroma with a V.5 resent dilated blood vessels in the upper dermis, thin epidermal collarette at the periphery. In the and if they are dark-red or black in color, this early stage of development numerous, newly means that they are partially or completely formed capillaries with narrow lumina and thrombosed [16, 29, 33, 34]. prominent endothelial cells, localized in the up- Vascular Lesions Chapter V.5 305 per dermis, become dilated as the lesion ages; face, lips, and oral mucosa, are the sites of predi- thus, in a fully mature lesion, there are numer- lection [7, 22]. Rare multiple lesions may be ous dilated capillaries lined by flattened endo- grouped or eruptive and disseminated in na- thelial cells [4]. These endothelial cells have ture. been shown to have non-replicating nature [31], indicating that cherry hemangioma may not be a true neoplasm. V.5.3.3 Dermoscopic Criteria Pyogenic granuloma has been reported that V.5.2.1.6 Management pyogenic granulomas cannot be diagnosed with more accuracy by dermoscopy than with naked Cherry hemangiomas are usually left alone un- eye [34]. Specific dermoscopic criteria of it have less cosmetically displeasing or prone to bleed- not yet been published. Recently, based on a ing. If necessary, they may be removed by morphological study of 13 patients, Zaballos et ­surgery (larger lesions), cryotherapy (10-s al. have evaluated the dermoscopic findings of freeze–thaw cycle with a 1-mm margin), elec- pyogenic granuloma. The most frequently ob- trosurgery or laser (potassium titanyl phosphate served features were reddish homogeneous area vascular laser [6], flash-lamp-pumped pulsed- (92%), white collaratte (84%), “white rail” lines dye laser, or continuous-wave krypton laser [1]). that intersect the lesion (30%), and ulceration Laser-treated lesions undergo inflammation, (46%). It was concluded that the absence of spe- necrosis, and eventual healing by 4 weeks [1]. cific criteria for other skin tumors and a reddish Laser treatment is paralleled by psychological homogeneous area surrounded by a white col- benefit also [10]. larette were the most frequent dermoscopic pat- tern in pyogenic granuloma. The histopatho- logical counterparts were attributed to the V.5.3 Pyogenic Granuloma proliferating capillaries for reddish homoge- neous areas, to the hyperplastic epithelium em- V.5.3.1 Definition bracing the lesion for “white collarette,” and to the fibrous septa surrounding the lobules for Pyogenic granuloma (lobular capillary heman- “white rail” lines [35]. A preliminary study on gioma, granuloma telangiectaticum, granuloma dermoscopic findings of pyogenic granuloma of pregnancy) is a shiny red, often friable, and was also carried out in our dermoscopy unit. In bleeding nodular lesion that develops rapidly, a period of 3 months, 11 histopathologically often following trauma, on the skin and mucosa confirmed cases of pyogenic granuloma were of children, young adults and pregnant women. included. The most commonly occurring fea- tures were reddish and whitish homogeneous area (82%), white collaratte (55%), “white fence,” V.5.3.2 Clinical Features the rods intersecting the lesion (82%), and ul- ceration (55%). It was concluded that the most Pyogenic granuloma arises as solitary, soft, frequent dermoscopic pattern in pyogenic gran- bright-red papule evolving rapidly in a few uloma was reddish and whitish homogeneous weeks and forming a darker, slightly peduncu- area with white fence (82%) and the other two lated nodule, measuring up to 2–3 cm, with a findings occurred in more than half of the pa- frequently eroded and crusted surface which tients (Fig. V.5.2b). Considering these two stud- may bleed very easily (Fig. V.5.2a) [25]. It is ies, it can be concluded that dermoscopy is a fa- common in one specific clinical setting, the gin- cilitative method in the diagnosis of pyogenic giva in pregnancy [8]. The areas subject to trau- granuloma. ma, the hands (especially the fingers), forearms, 306 F. Özdemir Fig. V.5.2. a Pyogenic granuloma, clinical view. A soft, dark-red nodule 8×10 mm in diameter with a shiny, partly eroded surface is shown. b Pyogenic granuloma, dermoscopy view (inset shows lower magnification). A reddish and whitish homogeneous area with a partial white collaratte (white arrow) and rods intersecting the lesion, namely, “white fence” (black arrows) and some ulceration at the periphery are shown V.5.3.4 Relevant Clinical Differential V.5.3.5 Histopathology Diagnosis The microscopic diagnosis is usually straightfor- Pyogenic granuloma includes malignant skin ward. Pyogenic granuloma is simply composed tumors, namely, hypo-apigmented melanoma, of aggregates of angiomatous lobules. These lob- basal cell carcinoma and squamous cell car­ ular aggregates of proliferating capillaries are cinoma, Kaposi’s sarcoma, glomus tumor, and within a fibromyxoid or collagenous stroma benign lesions such as multifocal infantile which is infiltrated by inflammatory cells. As the hemangiomas, cherry hemangioma, bacillary lesion grows old, the capillary lumens become angiomatosis, angiolymphoid hyperplasia with more dilated and evident. When the surface is eosinophilia, or milker’s nodule. The most im- ulcerated, the stroma becomes markedly infil- V.5 portant one, melanoma, cannot be excluded trated by neutrophils. In these lesions fibrin, with confidence without a biopsy.