Dermatology Online Journal

Linear verrucous hemangioma
Feroze Kaliyadan MD DNB MNAMS, A D Dharmaratnam MD, M G Jayasree, G Sreekanth
Dermatology Online Journal 15 (5): 15

Amrita Institute of Medical Sciences

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Abstract

Verrucous hemangioma is a rare, vascular malformation. It is usually present at birth, but there is often a gradual increase in size and number with age; occasionally it presents in later adulthood. The lesions usually present as hyperkeratotic, bluish, and partly confluent papules and plaques. Linear verrucous hemangioma is an even more rare presentation described in very few published reports. We report a 30-year-old male patient with linear verrucous hemangioma who experienced a sudden increase in the size of his verrucous hemangioma during adulthood.

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Introduction

Verrucous hemangioma is a rare, vascular malformation. It is usually present at birth and exhibits a gradual increase in size and number with age, but may also sometime present in later adulthood. The lesions usually present as hyperkeratotic, bluish, and partly confluent papules and plaques [1]. Linear verrucous hemangioma is an even more rare presentation with very few published reports. We report a 30-year-old male patient linear verrucous hemangioma presenting with a sudden increase in size of the lesions during adulthood.

Case synopsis

A 30-year-old male patient presented with a history of asymptomatic, verrucous skin lesions, restricted to the left leg, present since birth. The patient had never sought medical attention for this. Over the previous two years the patient noticed a sudden increase in the size of the lesions associated with pain and episodes of bleeding following trauma. The patient had no other significant co-morbidities and was not on any topical or systemic medication.

Figure 1	Figure 2
Figure 1. Verrucous lesions in a linear pattern on the lower leg Figure 2. Close-up view of leg lesions

Dermatological examination showed discrete verrucous, bluish-black plaques distributed over the left leg. The lesions were arranged in a linear configuration (Figs. 1 & 2). There was no significant difference in the length of the two limbs. Radiological and ultrasound imaging showed subcutaneous extension with no evident involvement of the bones or muscles. A biopsy was taken that showed epidermal hyperkeratosis and acanthosis with dilated capillary channels in the dermis (Figs. 3 & 4). The histological picture was consistent with verrucous hemangioma. The plaques were excised in multiple stages.

Figure 3	Figure 4
Figure 3. Histopathology showing hyperkeratosis,irregular acanthosis and dilated capillaries in the dermis (H&E x10) Fig 4 Histopathology showing dilated capiillary channels in the dermis (H&E x40)

The term 'verrucous hemangioma' was first used by Halter [2] and further described in detail as a distinct entity by Imperial and Helwig [3]. Verrucous hemangioma typically is localized, unilateral. Very few cases of linear verrucous hemangioma have been reported [1, 4, 5]. There is no consensus on whether linear verrucous hemangioma in general follows the distribution of Blaschko lines, primarily because there are so few cases reported [1, 6]. It has been proposed that these lesions may actually be following dermatomal patterns or that the linear arrangement represents genetic mosaicism [1].

Verrucous hemangiomas are characterized by expansion into the subcutaneous tissue. Hence deep surgical excision would be the treatment of choice [1, 6]. However, other superficial modalities such as laser, cryotherapy, ultrasonography, and combination therapies have been tried with varying amounts of success [7, 8].

This case is reported for the rarity of the linear verrucous hemangioma and also because of the unusual sudden increase in size during adulthood.

References

1. Wentscher U, Happle R. Linear verrucous hemangioma. J Am Acad Dermatol 2000 Mar;42(3):516-8. [PubMed]

2. Halter K. Hemangioma verrucosum mit osteoatrophie.Dermatol Z 1937; 75:275-9.

3. Imperial R, Helwig EB. Verrucous hemangioma: a clinicopathological study of 21 cases. Arch dermatol 1967;96:247-53. [PubMed]

4. Hayashi H, Shimizu T, Nakamura H, Shimizu H. Linear verrucous haemangioma on the abdomen. Acta Derm Venereol 2004;84:79-80. [PubMed]

5. Klein JA, Barr RJ. Verrucous hemangioma. Pediatr dermatol 1985;2:191-3. [PubMed]

6. Jain VK, Aggarwal K, Jain S. Linear verrucous hemangioma on the leg. Indian J Dermatol Venereol Leprol 2008;74:656-8. [PubMed]

7. Maejima H, Katsuoka K, Sakai N, Uchinuma E. Verrucous hemangioma successfully treated using 13-MHz ultrasonography Eur J Dermatol 2008;18:597. [PubMed]

8. Yang CH, Ohara K. Successful surgical treatment of verrucous hemangioma: a combined approach. Dermatol Surg. 2002;28:913-19. [PubMed]

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