Dermatology: Practical and Conceptual Observation | Dermatol Pract Concept 2016;6(4):8 35 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Case report The patient presented to our coastal regional Australian skin cancer clinic for an opinion on a new skin lesion on the lateral dorsum of his hand, first noticed two weeks prior. It was asymptomatic, without tenderness, bleeding, scale or itch. There was no history of trauma to the site or insect bite. There were no other similar lesions and no previous history of the lesions or history of previous skin cancers. At initial consultation the lesion was 8 x 6 mm in diameter, violaceous, plaque-like, with a slightly raised thin border and a mildly rough surface, without scale (Figures 1A and 1B). Dermatoscopy of the lesion showed a homogenous, non- pigmented violaceous lesion, without obvious vasculature at standard magnification. There were no keratin features or ulceration (Figure 2A). The most striking dermatoscopic fea- ture was the conspicuous shiny white structures throughout the lesion (Figure 2B). Because of the homogenous appearance of the lesion, its asymptomatic nature and the absence of classically worrying dermatoscopic features (such as pigmented clues, keratin features, polymorphic vessels, or ulceration), it was felt that the lesion was a benign dermal process, such as an inflamed lesion of granuloma annulare, and the patient was reassured and advised to return if the lesion was persisting or enlarging after a period of one month. The patient returned at three months, as the lesion had persisted and enlarged to 11 x 9 mm in diameter. Clinical and dermatoscopic features were unchanged and it was still asymptomatic, but the patient was concerned about its growth. Clinical and dermatoscopic photographs were taken with the patient’s consent, using a Canon PowerShot G16 First description of the dermatoscopic features of acquired elastotic hemangioma—a case report Tristan Hicks 1, Ian Katz2 1 Sun Doctors Ballina & Northern Rivers Skin Cancer Clinic, Ballina, Australia 2 Southern Sun Pathology, Sydney, Australia & Department of Medicine, University of Queensland, Brisbane, Australia Key words: acquired elastotic haemangioma, dermatoscopy, shiny white structures Citation: Hicks T, Katz I. First description of the dermatoscopic features of acquired elastotic hemangioma—a case report. Dermatol Pract Concept 2016;6(4):8. doi: 10.5826/dpc.0604a08 Received: June 5, 2016; Accepted: August 1, 2016; Published: October 31, 2016 Copyright: ©2016 Hicks et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Dr. Tristan Hicks, BMed, BBiomedSci, FRACGP. Email: trismiester@hotmail.com We present a case of acquired elastotic hemangioma (AEH), a rare, benign vascular tumor. A Cauca- sian male in his 60s presented with an asymptomatic, solitary, non-pigmented and violaceous lesion of short duration on the dorsum of his hand. The lesion had unique clinical, dermatoscopic and patho- logical features. Dermatoscopic images of the lesion are presented for characterization and histopatho- logical correlation that have not previously been published or described. ABSTRACT mailto:trismiester@hotmail.com 36 Observation | Dermatol Pract Concept 2016;6(4):8 many of which are arranged parallel to the epidermis, separated by bands of collagen. The endothelial cells display digital camera (Canon, Tokyo, Japan) coupled to a Dermlite DL3N dermato- scope (3Gen LLC, San Juan Capistrano, CA, USA), (Figures 1 and 2). A 4 mm punch biopsy was performed to rule out malignancy. Histopathological examination of the biopsy specimen was interpreted as showing hyperkeratosis and solar damage with a prominent fairly banal capillary proliferation in the dermis. This correlated poorly with the clinical picture and formal excision was sug- gested. The patient was recalled and the lesion was excised. Histopathological examination of the excisional specimen was interpreted as an acquired elastotic hemangioma based on the constellation of findings, including hyperkeratosis and flattened rete ridges, marked solar elastosis, and a superficial dermal horizontal band-like proliferation of capillaries (Figures 3A and 3B). There was no recurrence of the lesion at follow-up at three months. Discussion Acquired elastotic hemangiomas are rare, benign, usually solitary lesions occurring on sun-damaged skin of exposed areas in older adults, classi- cally the dorsum of forearms, with a slight female predilection. Initiation of progesterone therapy has been poten- tially implicated in the unusual scenario of multiple acquired elastotic heman- giomas in perimenopausal women [1]. AEH was first described by Requena et al in 2002 with a series of six cases [2]. Martorell-Calatayud et al in 2009 pub- lished a series of 14 cases that had been recorded over an 18-year period, all with similar clinical and histopathologic features. Most commonly, these lesions are mistaken clinically for basal cell carcinomas (BCC) [3]. AEH has a slow growth rate and is typically asymptom- atic, but clinically quite striking due to its violaceous appearance. Histopatho- logically, it exhibits a superficial dermal band-like proliferation of capillaries, a “hobnail” pattern without cellular atypia or mitoses. There is invariably a narrow band of uninvolved papillary Figure 1. Clinical (A) and macroscopic (B) views of AEH. Solitary, violaceous macular lesion on dorsum of hand (chronically sun-exposed region). Raised border without evidence of scale, crust or ulceration. [Copyright: ©2016 Hicks et al.] Figure 2. Non-polarizing (NPD) (A) and polarizing (PD) (B) dermatoscopy of AEH. Scale 1 mm intervals. Violaceous homogenous lesion without vessels but marked widespread shiny white structures visualized with polarized dermatoscopy. [Copyright: ©2016 Hicks et al.] Figure 3. Photomicrographs of the lesion, H&E stain. 40x (A) and 100x (B) magnification. Superficial dermal horizontal band-like proliferation of capillaries, with marked solar elas- tosis, some hyperkeratosis and flattening of rete ridges. The epidermis is otherwise normal. [Copyright: ©2016 Hicks et al.] Observation | Dermatol Pract Concept 2016;6(4):8 37 broma, the random shiny white lines and shiny white areas seen in BCCs, and the typical Wickham’s striae seen lichen planus [7,8]. Kaposi’s sarcoma has been described to commonly have a specific dermatoscopic polarising arte- fact, named “rainbow pattern,” where there are multi-colored shiny structures. It is postulated that this is due to the tightly packed capillary proliferation without intervening collagen [9]. In our example of AEH, there were no such coloration artefacts. We suggest that the specific polarization artefact of shiny white areas may be due to the horizontal band-like proliferation of capillaries in the superficial dermis with intervening collagen bundles. This specific feature, combined with the striking violaceous background and otherwise homogenous appearance of the lesion, may aid in the clinical recognition of this rare entity. Conclusion In summary, we present the first descrip- tion of the dermatoscopic features of acquired elastotic hemangioma. Our case revealed a violaceous plaque on chronically sun-damaged skin without vessels, but revealing prominent and widespread shiny white structures. References 1. Tillman N, Plumb SJ, Cleaver D, Cleaver L. Acquired Elastotic Hemangioma: A Case Report of Multiple Lesions Follow- ing Progesterone Therapy. http://c.ymcdn. com/sites/www.aocd.org/resource/resmgr/ Meeting_Resources/2015FallMeeting/ Syllabus/Posters/tillman15.pdf. 2015. Ac- cessed 9/5/16. dermis and a significant degree of solar elastosis. There is a normal appearing or atrophic epidermis and occasional hyperkeratosis [4]. Immunohistochemi- cal tests are not routinely required for diagnosis, although CD31 and CD34 immunostains will highlight the endo- thelial cells [5]. Most will also express D2-40, with a minority also being smooth muscle actin positive [3]. It has been suggested that AEH may have a lymphatic origin, but this hypothesis has been questioned by Tong and Beer [6]. In the literature, the clinical differential diagnosis of acquired elastotic hemangi- oma includes BCC, granuloma annulare, patch-stage Kaposi’s sarcoma, acquired tufted angioma, targetoid hemosiderotic hemangioma, low-grade angiosarcoma and capillary hemangioma [1,3,5]. Whilst there is an increasing appre- ciation of the clinical and histopatho- logical basis of AEH, dermatoscopy has never been described in these lesions. The dermatoscopy of this particular case showed a uniform, violaceous plaque without obvious vasculature or pigment that could aid in the diagnosis of a lesion prior to biopsy (Figure 2A). However, there were prominent and widespread shiny white structures dis- tributed evenly throughout the lesion (Figure 2B). Such shiny white structures are not encountered in other common lesions without other clues and are dif- ferent from both the short white perpen- dicular/orthogonal polarizing lines (also called shiny white streaks and chrysalis or crystalline structures) seen in lesions such as melanoma, Spitz naevi, lichen- oid keratosis (LPLK) and dermatofi- 2. Requena L, Kutzner H, Mentzel T. Ac- quired elastotic hemangioma: a clini- copathologic variant of hemangioma. J Am Acad Dermatol 2002;47:371. PMID: 12196746. 3. M a r t o r e l l - C a l a t a y u d A , B a l m e r N , Sanmartín O, Díaz-Recuero JL, Sangue- za OP. Definition of the features of ac- quired elastotic hemangioma reporting the clinical and histopathological char- acteristics of 14 patients. J Cutan Pathol 2010;37(4):460-4. PMID: 19615005 DOI: 10.1111/j.1600-0560.2009.01361.x. 4. Weedon D. Vascular tumours. In: Weedon’s Skin Pathology, 3rd ed. London: Churchill Livingstone, 2010:904. 5. Emanuel P, Acquired elastotic haeman- gioma pathology. DermnetNZ. http:// www.dermnetnz.org/pathology/elastotic- haemangioma-path.html Created 2013. Updated 2015. Accessed 9/5/16. 6. Tong PL, Beer TW. Acquired elastotic hemangioma: ten cases with immuno- histochemistry refuting a lymphatic origin in most lesions. J Cutan Pathol 2010;37(12):1259-60. PMID: 20950363. DOI: 10.1111/j.1600-0560.2010.01610.x. 7. Balagula Y, Braun RP, Rabinovitz HS, et al. The significance of crystalline/ chrysalis structures in the diagnosis of melanocytic and nonmelanocytic lesions. J Am Acad Dermatol 2012;67(2):194. e1-8. PMID: 22030020. DOI: 10.1016/j. jaad.2011.04.039. 8. Liebman TN, Rabinovitz HS, Dusza SW, Marghoob AA. White shiny struc- tures: dermoscopic features revealed under polarized light. J Eur Acad Der- matol Venereol 2012;26(12):1493-7. PMID: 22035217. DOI: 10.1111/j.1468- 3083.2011.04317.x. 9. Cheng ST, Ke CL, Lee CH, Wu CS, Chen GS, Hu SC. 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