Dermatology Online Journal

An unusual vascular tumor: Verrucous hemangioma
Melek Koc MD, Mukaddes Kavala MD, Emek Kocatürk MD, Ebru Zemheri MD, Ilkin Zindanci MD, Sibel Sudogan, Esra Kural MD
Dermatology Online Journal 15 (11): 7

Goztepe Training and Research Hospital, Istanbul, Turkey. emekozgur@yahoo.com

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Abstract

Verrucous hemangioma is an uncommon capillary or cavernous hemangioma with reactive epidermal changes of hyperkeratosis, acanthosis, and papillomatosis. These growths are usually located on the lower extremities and involvement is generally unilateral. A diagnosis of verrucous hemangioma should be considered in lesions especially with a hyperkeratotic nodular appearance located on the lower extremities.

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Introduction

Verrucous hemangioma is an uncommon, localized vascular malformation associated with reactive epidermal acanthosis, papillomatosis and hyperkeratosis on histological examination [1]. The lesions are bluish-red, well demarcated, soft, and compressible. In time, verrucous hemangiomas gradually enlarge and satellite nodules may arise. Thus, the older lesions of verrucous hemangioma acquire a warty surface [2].

Case report

Figure 1

A 59-year-old male presented complaining of a painful verrucous nodule located on his leg that had been enlarging slowly and had developed an overlying hemorrhagic crust. This lesion had been presented since birth and progressively enlarged. On dermatologic examination a verrucous, hyperkeratotic, well-circumscribed, hemorrhagic crusted, solitary brownish nodule with a diameter of 4 x 5 cm was seen on the distal part of the left leg (Fig. 1). Initially the lesion had been slowly growing, but progressive growth caused consequences such as tenderness and bleeding following minor trauma. There were no palpable lymph nodes in affected areas or in the inguinal region.

Figure 2

Histopathologic examination showed hyperkeratosis, papillomatosis, and acanthosis of the epidermis. There were multiple, thin-walled dilated blood-filled spaces in the superficial dermis (Fig. 2). A diagnosis of verrucous hemangioma was made. A magnetic resonance imaging showed a subcutaneus nodule with a diameter of 4 x 4 x 3 cm, limited by fascia and diagnosed as soft tissue tumor. The growth was excised and there has been no sign of recurrence for one year.

Discussion

Verrucous hemangioma has been reported in the literature with a variety of names including hemangioma unilateralis neviforme, unilateral verrucous hemangioma, angiokeratoma circumscriptum neviforme, nevus vascularis unius lateralis, keratotic hemangioma, nevus angiokeratoticus, nevus keratoangiomatosus, and papulous angiokeratoma [3]. In 1967, Imperial et al. introduced the term "verrucous hemangioma," and defined it as a congenital vascular malformation comprising a capillary or cavernous hemangioma in the dermis and subcutaneous tissue associated with reactive epidermal acanthosis, papillomatosis, and hyperkeratosis, distinguishing it from angiokeratoma [4].

Most verrucous hemangiomas are located on the lower extremities and involvement is generally unilateral. Lesions have usually been present since birth or have occurred in early childhood, although they may appear later or even in adult life [1, 2]. In our case the lesion had been present since birth and involved his left leg. The early clinical lesions of verrucous hemangioma are nonkeratotic, soft, and bluish-red in color. Over time they progressively enlarge and gradually become hyperkeratotic and verrucous, usually following trauma and infection. Verrucous hemangioma presents as circumscribed, warty papules or plaques or as papules and nodules arranged in linear or serpiginous configuration [2].

A variant has been described in which multiple lesions occurred mostly in a disseminated pattern, without evidence of systemic involvement [5]. Another variant, called digital verrucous fibroangioma is a distinct clinical and pathological entity consisting of dome shaped nodules of the dorsum of the fingers [6].

The diagnosis of verrucous hemangioma is mainly made by histopathological examination, although clinical correlation is required to make a correct diagnosis [3]. Histologically, verrucous hemangioma shows hyperkeratosis, variable epidermal acanthosis, and papillary telengiectasias overlying a deep cavernous or capillary hemangioma. The histological appearance closely resembles an angiokeratoma. However, in contrast to angiokeratoma, the vascular spaces in verrucous hemangioma also affect the lower dermis and subcutaneous tissues.

Clinically, the differential diagnosis of verrucous hemangioma includes angiokeratoma, Cobb syndrome, angioma serpiginosum, lymphangioma circumscriptum, verrucae, and pigmented tumors [2].

Verrucous hemangiomas do not resolve spontaneously and have a tendency to relapse. Early diagnosis is important to get a better cosmetic result. Verrucous hemangioma requires a large, deep excision. Incomplete excision leads to recurrence because of deeper components. Cryosurgery, electrocautery, and laser therapy can be used for smaller lesions [1]. Yang and Ohara performed surgery in combination with pulse dye laser, CO₂ laser, or argon laser in 23 patients with verrucous hemangioma and reported that a combination approach using surgical reconstruction and laser is necessary for large and extensive lesions [7]. Surgery with adequate margins was performed in our patient and the result was good with no recurrence after one year.

As a result, a diagnosis of verrucous hemangioma should be considered in vascular papules, nodules, and plaques, especially those with a hyperkeratotic nodular appearance located on the lower extremities; it must be confirmed by histopathological examination.

References

1. Wang G,Li C, Gao T. Verrucous hemangioma. Int J Dermatol. 2004 Oct;43(10):745-6. [PubMed]

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

3. Calduch L, Ortega C, Navarro V, Martínez E, Molina I, Jordá E. Verrucous hemangioma: report of two cases and review of the literature. Pediatr Dermatol. 2000 May-Jun;17(3):213-7. [PubMed]

4. Imperial R, Helwig EB. Verrucous haemangioma: a clinicopathological study of twenty one cases. Arch Dermatol, 1967; 96(3) : 247-253. [PubMed]

5. Cruces MJ, de la Torre C. Multiple eruptive verrucous hemangiomas: a variant of multiple hemangiomatosis. Dermatologica 1985;171:106-111. [PubMed]

6. Kohda H, Narisawa Y. Digital verrucous fibroangioma: a new variant of verrucous hemangioma. Acta Derm Venereol 1992;72:303-304. [PubMed]

7. Yang CH, Ohara K. Successful surgical treatment of verrucous hemangioma: a combined approach. Dermatol Surg. 2002 Oct;28(10):913-19; discussion 920. [PubMed]

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