Experts clarify verrucous hemangioma confusion

Quebec City, Quebec - The diagnosis of angiokeratoma circumscriptum should be supplanted with verrucous hemangioma, and the lesion should be treated with surgery in most cases, according to a retrospective case series presented at the annual meeting of the Canadian Dermatology Association.

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“The reason we undertook this study is that there was confusion about what was an angiokeratoma, which could be better treated with laser, and the verrucous hemangioma, which could be better treated with surgery,” says Catherine McCuaig, M.D., F.R.C.P.C., a pediatric dermatologist at CHU Sainte-Justine in Montreal, and an associate professor of dermatology and pediatrics at the University of Montreal.

The series included 20 cases, which had been referred to the tertiary care institution. All of the lesions in the series were biopsied, and the mean age of the patients was 4.1 years old. The lesions were located mainly on the lower extremities, in some cases on the forearms, and on the abdomen.

Defining distinctions

The two lesions have very similar clinical presentation, but Dr. McCuaig drew several distinctions between angiokermatomas and verrucous hemangiomas. Verrucous hemangiomas are always congenital, well-circumscribed, and thicken with time. There is often oozing and/or bleeding present. Their incidence is very rare.

By contrast, angiokeratomas are acquired dermatoses that are smaller, superficial and occasionally bleed. They can feature superficial, crusted papules.

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“Verrucous hemangioma is always congenital while the angiokeratoma, for the most part, is quiet and often overlies another vascular formation, primarily a lymphatic malformation,” says Dr. McCuaig, adding that a histopathological examination should be performed to confirm the diagnosis of verrucous hemangioma. “We think the term angiokeratoma circumscriptum should be let go.”

There are no guidelines outlining the most efficacious treatment for verrucous hemangiomas, Dr. McCuaig says.

Another difference between the two types of lesions is their depth: angiokeratomas only involve the papillary dermis while with verrucous hemangiomas, the blood vessels extend into the dermis and subcutaneous fat. This difference between the two entities underlines the need for a biopsy of sufficient depth, for a biopsy that consists of a superficial tissue sample can result in an incorrect diagnosis.¹

NEXT: Treatment options

Treatment options

Surgery effectively treats the verrucous hemangioma with no recurrence and patients satisfaction. When the surface area of a verrucous hemangioma is extensive and it is too large to resect, laser therapy should be the management choice. Not all lasers are effective in managing these hemangiomas, Dr. McCuaig explains.

A pulsed dye laser eliminates keratotic papules, but the overall improvement in treating verrucous hemangiomas is somewhat limited, according to Dr. McCuaig.

“If you are trying to palliate a verrucous hemangioma, and you use a pulsed dye laser, it doesn’t go particularly deep, and the treatment might not be definitive,” she says. “Some patients (in this series), were satisfied enough with the pulsed dye laser because it stopped the bleeding. These were hemangiomas that were too big to excise.”

The CO₂ laser, while effective in treating an angiokeratoma, did not effectively treat verrucous hemangiomas, Dr. McCuaig says. With one of the patients in the series, there was clearance of the lesion followed by recurrence of the hemangioma one month after treatment with the CO₂ laser. Although it is not their own clinical practice, Dr. McCuaig points to experience in the published literature that demonstrates efficacy with the Nd:YAG laser to manage larger verrucous hemangiomas.²

“In some ways, we are reporting negative results for us (clinicians) all to better learn,” she says. “The surgical approach would have been better from the beginning (in the case where there was recurrence). Choosing the laser route, the Nd:YAG laser is preferred. You need to know full well that there can be significant scarring (after laser treatment).”

Complications such as bleeding, pain and infection arise with either surgical or laser treatment.

“Complications are inherent to any surgery or the use of a laser,” Dr. McCuaig says.

References:

1. Pavithra S, Mallya H, Kini H, Pai GS. Indian J Dermatol. 2011;56(5):599-600

2. Palacios JMS, Boixeda P, Rocha J, et al. Lasers Med Sci. 2012;27(3):681-684