Verrucous plaque over leg in a young male

The term “verrucous hemangioma” was first used by Halter in 1937 but was first described as a separate entity by Imperial and Helwig in 1967.1 The term is a misnomer as the lesion is not a hemangioma but a malformation.2 Verrucous hemangioma has been classified as a congenital vascular malformation that often occurs at birth or during early childhood, and the most common site is the lower extremities.1, 3 Verrucous hemangiomas do not regress spontaneously. They must be treated with local excision or electrocautery, and larger lesions require extensive and deep excision, possibly requiring grafting. A 17-year-old boy presented with three mildly painful, raised, blackish lesions over his left leg since birth. The individual lesions first presented at birth as a raised, dull red to blackish plaque, which evolved over the last 3–4 years to its present size and was associated with pain and occasional bloody discharge. Cutaneous examination revealed three tender, well-defined, deep bluish to blackish verrucous plaques with a hyperkeratotic surface over the medial aspect of the left distal leg (Fig. 1). On dermatoscopic examination, prominent hyperkeratosis with multiple round to oval reddish-blue lacunae was observed (Fig. 2). On histopathological examination, the epidermis showed hyperkeratosis and prominent papillomatosis. Few capillaries in the upper dermis showed the presence of fibrin thrombi. The deeper dermis showed the proliferation of small thin-walled vascular channels extending to the subcutaneous tissue (Fig. 3). MRI of the left lower limb showed sheet-like, lobulated lesions along the postero-medial aspect of the distal leg involving the skin, subcutaneous tissue and reaching up to the underlying fascia. No involvement of the underlying muscle was seen. The diagnosis of verrucous hemangioma was made based on clinical, histopathological and radiological findings. Vascular surgery and interventional radiology opinions were sought Further, the patient has been planned for wide local excision by the vascular surgery department. The lesions are generally unilateral, although bilateral and serpiginous distributions have been described in the literature. Early lesions are generally soft, compressible, well-circumscribed, and bluish-red in colour. Later in life, they gradually become hyperkeratotic and verrucous.4 Clinically, the lesions of verrucous hemangiomas can be very similar to angiokeratomas, and incomplete removal of verrucous hemangiomas may lead to recurrence of lesions from deeper components. Angiokeratomas are acquired in nature and present as punctate lesions of 1–5 mm, which coalesce to form plaques.5 The other differential diagnoses include verrucous epidermal nevus, verrucous carcinoma, verruca vulgaris, Cobb's syndrome, and rarely even malignant melanoma.6, 7 MRI is the preferred diagnostic method, providing clear delineation of the dermal and subcutaneous planes of these lesions while aiding in the guidance of biopsies.8, 9 Histopathological examination remains the gold standard for diagnosis, which shows hyperkeratosis, variable epidermal acanthosis, and papillary telangiectasias overlying a deep cavernous or capillary hemangioma. The histological appearance is very similar to angiokeratoma. In contrast to angiokeratomas, the vascular spaces of verrucous hemangiomas also affect the lower dermis and subcutaneous tissue.10 Verrucous hemangiomas do not regress spontaneously. Larger lesions require extensive and deep excision, possibly requiring grafting.11 The recurrence rate after surgery is more than 33%, but the likelihood of recurrence decreases when sufficient margins and the entire depth of the lesion are adequately excised.1 Present case hence suggests to consider the possibility of verrucous hemangioma if deep erythematous to bluish warty nodules and plaques are observed on the lower limb. The variety of configurations that verrucous hemangioma manifests as can lead to confusion, necessitating clarification through dermatoscopy and biopsy. Patient consent was obtained. K B Meghana: Data curation; writing – original draft. Apoorva Sharma: Conceptualization; data curation; resources; supervision; visualization. Debajyoti Chatterjee: Supervision; validation; visualization; writing – review and editing. Tarun Narang: Methodology; supervision; validation; visualization; writing – review and editing.