Dermatology: Practical and Conceptual


Observation  |  Dermatol Pract Concept 2017;7(1):8 43

DERMATOLOGY PRACTICAL & CONCEPTUAL
www.derm101.com

Introduction

Targetoid hemosiderotic hemangioma (THH) or hobnail 

hemangioma (HH) is a benign vascular lesion, which mainly 

affects young people with a prevalence in men.

The classical clinical presentation is a ring-shaped vas-

cular lesion having a targetoid appearance, with a central 

purple-brown papule surrounded by a thin pale area and an 

ecchymotic ring on the outside [1,2]. However, HH tends to 

undergo cyclical changes and, therefore, the clinical presenta-

tion can vary. Thus, depending on the staging, the differential 

diagnosis considered should include lesions such as heman-

gioma, angiokeratoma, Kaposi’s sarcoma, dermatofibroma, 

insect-bite reactions, melanocytic nevus and melanoma.

Dermoscopy is a non-invasive diagnostic technique useful 

for diagnosing both melanocytic and non-melanocytic pig-

mented lesions, as well as vascular skin lesions. Dermoscopic 

features and patterns of HH have been increasingly docu-

mented and have proven to be sufficient to make a clinical 

diagnosis in many cases. Here, we present a facial lesion in 

which both the clinical presentation and dermoscopy were 

atypical. The presence of arborizing vessels in the dermo-

Arborizing vessels in a targetoid hemosiderotic 
hemangioma: mistaken dermoscopic diagnosis 

of basal cell carcinoma
María L. Enei1, Francisco M. Paschoal2, Rodrigo Valdes3

1 Dermatology, Brazilian Society of Dermatology, Iquique, Chile,

2 Dermatology, ABC School of Medicine, FMABC, São Paulo (SP), Brazil

3 Institute of Histopathology, Histonor, Antofagasta, Chile

Key words: dermoscopy, hobnail hemangioma, targetoid hemosiderotic hemangioma, basocellular carcinoma

Citation: Enei ML, Paschoal FM, Valdes R. Arborizing vessels in a targetoid hemosiderotic hemangioma: mistaken dermoscopic diagnosis 
of basal cell carcinoma. Dermatol Pract Concept. 2017;7(1):8. DOI: https://doi.org/10.5826/dpc.0701a08

Received: October 24, 2016; Accepted: November 26, 2016; Published: January 31, 2017

Copyright: ©2017 Enei 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: María Leonor Enei, MD, Dermatologist, 2030, Santiago Polanco Street, 2°, office 10, Iquique, Chile, 1100000. 
Tel. +56 572343804. Email: leonorenei@vtr.net

Targetoid hemosiderotic hemangioma (THH) or hobnail hemangioma (HH) is a benign vascular le-
sion that presents with the classical clinical presentation of a ring-shaped tumor having a targetoid 
appearance, with a central purple-brown papule surrounded by a thin pale area and an ecchymotic 
ring on the outside. Dermoscopic features and patterns of HH have been documented and have proven 
to be sufficient to establish a clinical diagnosis in many cases.

We present a facial lesion in which both the clinical presentation and dermoscopy were atypical. The 
presence of arborizing vessels in the dermoscopic pattern, never before described for this lesion, led us 
to the diagnosis of basocellular carcinoma (BCC). We also report the changes in this pattern experi-
enced over 12 months of progression and their correlation with the histopathologic findings.

ABSTRACT

mailto:leonorenei@vtr.net


44 Observation  |  Dermatol Pract Concept 2017;7(1):8

Discussion

The histopathogenesis of HH is not 

yet clear. It is accepted that a local pre-

cipitating factor (trauma or hormonal 

influence) leads to the development of 

scopic pattern, never before described 

for this lesion, led us to the diagnosis 

of basal cell carcinoma (BCC). We also 

report the changes in this pattern expe-

rienced over 12 months of progression 

and their correlation with the histo-

pathological findings.

Clinical Case
A 68-year-old man presented for consul-

tation for a lesion on the nasal dorsum, 

which was asymptomatic with a few 

months of progression. There was no 

history of trauma or preexisting lesions 

in the area.

On clinical examination a pig-

mented papule was observed (5 x 5 

mm) with a smooth surface and regular 

edges (Figure 1). Dermoscopic analysis 

with a FotoFinder video dermoscope 

(FotoFinder Systems GmbH, Bad Birn-

bach, Germany) detected the presence of 

arborizing vessels throughout the lesion, 

a bluish-gray ovoid structure, multiple 

cluster brown points and diffuse brown 

pigment (Figure 1).

These findings led us to the diag-

nosis of BCC and indicated resection. 

However, the patient returned after 

12 months without presenting notable 

clinical changes. A new dermoscopy 

showed the presence of a dense bluish-

brown pigment following a reticular 

distribution and the disappearance of 

most arborizing vessels; the extreme 

distal vessels remained in some areas 

and telangiectasia in others (Figure 2).

An excisional biopsy of the lesion 

was performed, and the tissue was sent 

for histopathologic analysis, which 

reported the presence of irregularly 

dilated blood vessels mainly in the 

superficial dermis having a prominent 

endothelium composed of relatively 

small cells, with little cytoplasm and 

hyperchromatic nuclei that projected 

towards the lumen (hobnail aspect). Also 

the presence of sparse aemosiderin and 

hemosiderotic histiocytes in the dermis 

was reported (Figure 3). The diagnosis 

was HTT. The patient has been managed 

for 10 years without further recurrence.

Figure 1. Clinical appearance. Pigmented papule, 5 mm diameter, nasal dorsum, brown to 

black, well delimited. The surrounding skin is of normal appearance. (b) Dermoscopic analy-

sis: arborizing vessels (arrows), multiple brown points (circle) and a large blue-gray oval 

nest structure (triangle). There is little brown pigment dispersed through the lesion (star). 

[Copyright: ©2017 Enei et al.]

microshunts between the lymphatic and 

blood vessels in the dermis. The capil-

lary pressure of the latter would cause 

erythrocytes to pass into the lymphatic 

spaces forming aneurysmal structures. 

In older lesions, the emerging lymph 

Figure 2. (a) Clinical appearance after one year of evolution. The papule shows no significant 

changes, including size and color (b) Dermoscopic analysis: the centre of the lesion displays 

a dense blue-brown pigment with reticular distribution (stars). At the periphery are the ex-

treme distal vessels from Figure 1 (black arrows) and artifacts (black triangles). Two round, 

yellowish brown structures are in the middle of the pigmented area (segmented arrows). 

[Copyright: ©2017 Enei et al.]



Observation  |  Dermatol Pract Concept 2017;7(1):8 45

for skin lesions. The first reference to 

epiluminescence microscopy for HH 

dates back to 1998 and describes well-

demarcated red lagoons in the papular 

region of the lesion [6]. Since then, no 

more than 12 reports based on this tech-

nique have been published, covering 

a total of 48 lesions studied (Table 1; 

[5-16]).

We highlight the series of 35 cases 

recently published by Zaballos et al [7] 

in which the authors were able to estab-

lish that the unequivocal dermoscopic 

pattern for HHT is only present in 52% 

of lesions and is represented by the pres-

ence of lagoons in the center, a yellowish 

circular intermediate area, and a purple 

or ecchymotic ring on the periphery.

In this series, the most common pat-

tern (71.2%) consisted of central lagoons 

and a homogeneous area on the periph-

ery, which can also be observed in other 

vascular tumors and 22.8% of the lesions 

were fully occupied by a reddish purple 

or reddish brown homogeneous area.

This variety of dermoscopic patterns 

correlates with the different stages of 

tumor progression. Thus, the prolifera-

tion of dilated vessels in the superficial 

dermis correlates with the lagoon struc-

tures; the hemorrhagic phenomena are 

reflected in the ecchymotic ring, and 

fibrosis of older lesions gives rise to 

whitish homogeneous structures. In our 

case, neither of the two dermoscopic 

evaluations showed the structures or 

patterns described to date for HH. Thus, 

vessels become clogged, causing the dis-

appearance of these ectatic vessels in the 

papillary dermis. Additionally, there is 

increased deposition of hemosiderin and 

subsequent fibrosis [3]. Thus, the histol-

ogy shows a vascular lesion confined to 

the dermis, with a biphasic pattern. The 

upper portion has dilated and irregular 

vascular spaces with thin walls delin-

eated by endothelial cells display a “hob-

nail” aspect, i.e., round, with little cyto-

plasm and a large nucleus that protrudes 

into the vascular lumen. In the lower 

portion, thinner vascular spaces appear 

to cut their way through the collagen 

bundles. Local deposits of hemosiderin 

or siderophages are common, secondary 

to a local hemorrhagic processes.

Although studies based upon immu-

nohistochemistry lead to recognition of 

the lymphatic origin of HH [4], recent 

observation of these markers suggests 

also a biphasic histological behavior 

for these lesions. Takayama, et al [5], 

found not only positivity for CD31 and 

D2-40 in the upper portion of the hob-

nail, confirming the lymphatic nature 

of the lesion, but also positivity for 

CD31, CD34-factor VIII, and α-SMA, 
suggesting an endothelial origin of the 

lower portion. As far as diagnosis is con-

cerned, this is often difficult, especially 

if the lesion lacks the typical targetoid 

appearance.

Dermoscopy is a noninvasive imag-

ing technique that allowed us to signifi-

cantly increase the diagnostic precision 

we highlight that, as far as we know, this 

is the first time these arborizing vessels 

have been mentioned for this lesion. 

This finding, in conjunction with the 

blue, round structure, was the pattern 

that led us to posit the diagnosis of BCC.

However, several lesions have been 

reported to predominantly feature 

arborizing vascular structures, making 

it impossible to discard the diagnosis of 

BCC. Some examples are hidradenoma, 

trichoblastoma, trichoepithelioma, cyl-

indroma, hydrocystoma, and poroma.

Other vascular structures, such as 

points or polymorphous irregular ves-

sels, have been described in HH in the 

central portion of the lesion, which have 

been linked to deeper vessels in the der-

mis [7].

On the other hand, we believe that 

the round, blue structure and brown 

points, in addition to the diffuse brown 

pigmentation of the first image (Figure 

1), corresponded as a set to an ecchy-

motic point and initial deposition of 

hemosiderin and siderophages in the 

middle dermis, respectively; this phe-

nomenon increased until becoming a 

dense network in the center of the lesion 

after 12 months of progression, covering 

the globular structure and brown points.

It was interesting to compare the 

two dermoscopic studies and observe the 

collapse of the central portion of the ves-

sels with the persistence of extreme fine 

vessels and telangiectasias. The emer-

gence of two round, yellowish brown 

Figure 3. Histopathologic analysis. Irregularly dilated blood vessels mainly in the superficial dermis, having a prominent endothelium 

composed of relatively small cells (a), with little cytoplasm and hyperchromatic nuclei, projected towards the lumen (hobnail aspect)(b). 

[Copyright: ©2017 Enei et al.]

A B



46 Observation  |  Dermatol Pract Concept 2017;7(1):8

and immunohistochemical analysis of 62 cases. J Cutan Pathol. 

1999;26(6):279-286.

2. Trindade F, Kutzner H, Tellechea Ó, Requena L, Colmenero I. 

Hobnail hemangioma reclassified as superficial lymphatic malfor-

mation: a study of 52 cases. J Am Acad Dermatol. 2012;66:112-

115.

3. Guillou L, Calonje E, Speight P, Rosai J, Fletcher CD. Hobnail 

hemangioma: a pseudomalignant vascular lesion with a reap-

praisal of targetoid hemosiderotic hemangioma. Am J Surg Pathol. 

1999;23:97-105.

4. Franke FE, Steger K, Marks A, Kutzner H, Mentzel T. Hobnail 

hemangiomas (targetoid hemosiderotic hemangiomas) are true 

lymphangiomas. J Cutan Pathol. 2004;31:362-367.

5. Takayama R, Ueno T, Futagami A, Ansai S, Fukumoto T, Sae-

ki H. Hobnail hemangioma: a case report. J Nippon Med Sch. 

2015;82(3):151-155. 

6. Avci O, Soyal MC, Sagol O, Gunes AT. Targetoid hemosiderotic 

hemangioma. J Eur Dermatol Venereol. 1998;11:186-187.

7. Zaballos P, Llambrich A, Del Pozo LJ, et al. Dermatology. 2015;231 

(4):339-344.

8. Yang G, Tan C. Red-violaceous lacunae with a yellowish ecchymot-

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structures in the middle of the pigmented area is also reported 

(Figure 2), which could correspond to ectatic vessels in the 

superficial dermis described in the histopathology report, 

similar to the structures observed in the lymphangiomas. In 

neither of the two stages did we observe homogenous areas, 

lagoons, thin pigmented networks, or whitish structures, such 

as the ones described in published cases of HH.

In conclusion, arborizing vessels and blue clods are not 

unique to BCC and have been described for other tumors. 

However, this is the first time that they are described in a 

lesion of HH. We highlight this case because of its unusual 

dermoscopic presentation. Therefore, we add BCC to the 

differential diagnosis of HH and highlight the fact that when 

the clinical presentation is uncharacteristic, histopathology 

continues to be the gold standard for diagnosing this lesion.

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TABLE 1. Published Dermoscopic Descriptions of Hobnail Hemangioma

Year 

published

Reference 
number

Number 
of

 cases

DC pattern Vessels HP
Dermoscopy 
monitoring

Clinical and DC 
diagnosis

2016 8 1 B No No Yes Yes

2015 7 35 A (71.4%)
B (52%)

C (22.8%)

Dots and 
polymorphous (40%)

Yes Not described Yes
(77%)

2015 9 1 D No Yes No No

2015 10 1 A No No Yes Yes

2015 5 1 B No Yes Yes
(4 weeks)

Yes

2014 11 1 E No Yes No No

2010 12 1 A No Yes No No

2009 13 1 D No Yes No No

2009 14 1 A No No Yes
(3 months)

Yes

2007 16 1 A-D No Yes No No

2005 16 3 B No Yes Yes Yes

1998 6 1 A No Yes Yes
(34 days)

Yes

A: Central red and dark peripheral circular lacunae and reddish-violaceous homogeneous area / violaceous nuclei surrounded by a 
pale halo / well-defined network of circular blebs.
B: Red lacunae located at the center, an intermediate yellow circular homogeneous area, and a violaceous or ecchymotic homogeneous 
ring on the periphery. C: Homogeneous area.
D: Red, roundish lagoon-like areas in the focus of the injury, with a fine pigment network at the periphery. E: Slight peripheral pig-
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