CASE REPORT
Recurrent Targetoid Hemosiderotic Hemangioma in a 26-Year-Old Man
LT Sarah Broski Gendernalik, DO, MC (FS), USN LT James D. Gendernalik, DO, MC (FS), USN
A 26-year-old previously healthy man presented with a 6-mm violaceous papule that had a surrounding 1.5-cm annular, nonblanching, erythematous halo on the right-sided flank. The man reported the lesion had been recurring for 4 to 5 years, flaring every 4 to 5 months and then slowly disap - pearing until the cycle recurred. Targetoid hemosiderotic hemangioma was clinically diagnosed. The lesion was removed by means of elliptical excision and the condition resolved. The authors discuss the clinical appearance, his - tology, and etiology of targetoid hemosiderotic heman - giomas. J Am Osteopath Assoc . 2011;111(2);117-118
argetoid hemosiderotic hemangiomas (THHs) are a com - Tmonly misdiagnosed presentation encountered in the primary care setting. In the present case report, we aim to pro - Figure. A 6-mm violaceous papule with a surrounding 1.5-cm annular, nonblanching, erythematous halo in a 26-year-old man. vide general practitioners with an understanding of the clin - ical appearance, pathology, and prognosis of THH.
Report of Case A 26-year-old previously healthy man presented to our primary around it and itched and burned each time it developed. The care clinic with a 6-mm violaceous papule with a surrounding lesion faded completely to normal-appearing skin between 1.5-cm annular, nonblanching, erythematous halo on the right- episodes, without evidence of a papule or postinflammatory sided flank ( Figure ). The patient stated that the lesion had hyperpigmentation. The patient had sought medical treat - been recurring for 4 to 5 years, flaring intermittently every 4 to ment in the past, but each time, the lesion had resolved before 5 months and then slowly disappearing until the cycle recurred. he was able to see a physician. The day he presented to the The patient noted the lesion typically developed a red ring clinic was the first appointment he was able to secure during the acute phase of the lesion’s cycle. The patient was diag - nosed clinically as having THH, or hobnail hemangioma, which is a rare benign solitary vascular tumor. 1,2 The lesion was removed by means of elliptical excision and the THH was resolved.
From the Department of Aviation Medicine at the Naval Hospital Oak Harbor Comment in Washington. A THH lesion can develop anywhere on the body but most fre - The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Depart - quently occurs on the trunk and extremities. The tumor typi - ment of Defense, or the United States government. cally develops in patients aged 7 to 55 years 2,3 and has a male Financial Disclosures : None reported. to female incidence of 1 to 1. 4 Patients with THH often present Address correspondence to LT Sarah B. Gendernalik, DO, MC (FS), USN, Department of Aviation Medicine, Naval Hospital Oak Harbor, 3475 N Saratoga with acute onset of a violaceous papule or nodule with a tran - St, Oak Harbor, WA 98278-4927. sient ecchymotic halo, 1 which gives the lesion the targetoid E-mail: [email protected] appearance. Over time, the halo may expand peripherally Submitted April 1, 2009; revision received September 24, 2009; accepted and become swollen and tender, eventually disappearing and October 7, 2009. leaving only the central papule. 2 The duration of THH ranges
Gendernalik and Gendernalik • Case Report JAOA • Vol 111 • No 2 • February 2011 • 117 CASE REPORT
from 1 week to 2 decades. 4 As in the present case, THH is Conclusion often recurrent or episodic in nature until excision. The lesion When encountering a violaceous papule or nodule in the pri - is often misdiagnosed as a melanocytic nevus, hemangioma, mary care setting, physicians should include THH in their Kaposi sarcoma, or dermatofibroma. differential diagnosis. Targetoid hemosiderotic hemangioma can be determined from other vascular lesions by means of clinicopathologic cor - References relation. 3 Histologically, THH is characterized by a dermal 1. Hudgens JL, Fleet SL, Davis LS. Purpuric nodule on the shoulder. Arch Der - matol . 2006;142(10):1351-1356. vascular proliferation, specifically prominent, dilated, thin- 4,5 2. Ly S, Versapuech J, Vergier B, Beylot-Barry M, Beylot C. Targetoid walled vessels in the papillary dermis. Prominent endothe - hemosiderotic hemangioma. Eur J Dermatol. 1998;8(8):583-585. lial cells create a “hobnail” appearance. 4 Erythrocyte extrava - 3. Auerbach MJ, Willard RJ. Pathologic quiz case: a 23-year-old man with a sation and hemosiderin deposition are often present and may solitary red calf lesion. Arch Pathol Lab Med. 2003;127(6):e265-e266. http://www cause the halo appearance. 1 .archivesofpathology.org/doi/full/10.1043/1543-2165%282003%29127%3Ce265 Etiologies of THH have been discussed in the literature %3APQCAYO%3E2.0.CO%3B2. Accessed January 13, 2011. and vary widely. Many researchers believe this lesion to be a 4. Christenson L, VanBeek M, Davis D. Targetoid hemosiderotic hemangioma reactive process, resulting from trauma to a pre-existing heman - occurring in a father and son. Arch Dermatol. 2000;136(12):1571-1572. gioma or lymphangioma. 5 Lesions have also been known to 5. Christenson LJ, Stone MS. Trauma-induced simulator of targetoid demonstrate clinical variations during the menstrual cycle hemosiderotic hemangioma. Am J Dermatopathol. 2001;23(3):221-223. and pregnancy. 3,6 However, given the equal incidence of THH 6. Fernandez-Flores A, Manjon AJ, Campo F. Clinical changes in “true” hob - nail hemangioma during menstruation. Bratisl Lek Listy. 2008;109(3):141- in men and women, hormonal influence is likely a contributing 143. rather than causal factor in THH etiology. One case report 4 sug - gests familial predilection or similar environmental exposure may be a factor in the development of THH. Although THH is a benign vascular proliferation, it can be removed for diagnostic or cosmetic purposes. Excision after the lesion has partially regressed may improve cosmesis. 1
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