Angiokeratoma of the glans penis: clinical, histopathological and dermoscopic correlation
1 Department of Dermatology. Hospital General Universitario Gregorio Gregorio Marañón, Madrid, Spain. email@example.com Department of Pathology. Hospital General Universitario Gregorio Marañón, Madrid, Spain
Angiokeratoma is a benign vascular lesion characterized by vascular ectasia in the upper dermis and hyperkeratosis. We report a case with lesions on the glans penis, a very rare location. In addition, we report the dermoscopic findings.
A 71-year-old man was seen in our outpatient clinic because of lesions on his glans penis. These lesions persisted for about 3 months, and were asymptomatic. He has not received any kind of treatment.
The patient was diagnosed 1 year earlier with adenocarcinoma of the prostate, Gleason 6(3+3), and treated with local, radical radiotherapy with an excellent response. He finished this treatment 5 months before lesions appeared.
Examination revealed several reddish-purple papules, up to 4 mm in diameter. The papules had central erosions surrounded by hyperkeratosis. They were arranged around the meatus of the penis. They were not tender to palpation and did not clear with diascopy. These lesions arose on a whitish sclerotic bed (Figs. 1 and 2).
Under dermoscopic examination, red oval lacunae and red points, with a peripheral white collarette corresponding to the clinical hyperkeratosis were noted. In addition, there were some areas among the main lesions with pin-point vessels (Figs. 3 and 4).
Histology revealed dilated and congested, medium-sized blood vessels occupying the upper third of the dermis. Some of these blood vessels were thrombosed. Endothelial cells were normal, with no atypia or mitoses. The overlying epidermis showed hyperkeratosis with parakeratosis, as well as acanthosis with irregular enlargement of the rete pegs (Figs. 5 and 6).
The lesions were diagnosed as multiple angiokeratomas of the glans penis. We decided to avoid physical treatments and recommended emollients only.
Angiokeratomas are benign vascular lesions, characterized by ectasia of blood vessels in the upper third of the dermis, often accompanied by hyperkeratosis. Angiokeratomas can be classified into five principal types: 1) angiokeratoma of Mibelli, reported by Bazin in 1862, and defined by Mibelli in 1889, characterized by papules or verrucoid nodules, more common in men, and involving bony prominances ; 2) angiokeratoma of Fordyce, described by Fordyce in 1896, more common in adult or old men, located in the scrotum, thighs, abdomen and groins, and vulva in women, usually related to conditions with elevated venous pressure ; 3) angiokeratoma circumscriptum, first reported by Fabry in 1915, usually presenting as papules with a tendency to confluence into plaques ; 4) multiple or solitary types, usually involving the lower extremities; and 5) angiokeratoma corporis diffusum, that consists of multiple papules in clusters, usually associated with one of several enzyme disorders .
Individual lesions are bright red-purple to black, round to oval papules. They are sometimes dome-shaped, with hyperkeratosis and hemorrhagic crusts. The angiokeratomas are usually asymptomatic, but they can occasionally bleed with slight trauma. The etiology remains unclear, but several factors have been implicated such as increased venous blood pressure or primary degeneration of vascular elastic tissue.
Histopathological features of the five types enumerated are similar to those found in our patient. Medium-sized vessels in the superficial dermis are ectatic and congested, sometimes thrombosed. The endothelium is a single layer, with neither cellular atypia nor mitoses. The epidermis shows hyperkeratosis and acanthosis with irregular enlargement of the rete pegs.
Dermoscopy is a useful tool in differentiating between angiokeratoma and other lesions such as melanoma. Angiokeratoma is characterized by a lacunar or multicomponent pattern, with large, well-delimited, round to oval, and red to black areas. There is also a whitish veil attributed to the acanthotic and hyperkeratotic epidermis .
Several options for angiokeratoma management were reported, but there is no established protocol. Furthermore, treatment is not always necessary because angiokeratomas are often asymptomatic. There have been reported cases treated with cryotherapy, curettage, electrodesiccation, carbon dioxide laser, Nd-YAG laser, and pulsed dye laser [3, 5].
Our case presents some interesting peculiarities. The lesions arose on an uncommon site, the glans penis, without any other area of involvement. On the basis of location, our patient appears to have the Fordyce type of angiokeratomas, similar to two other reported cases [2, 5]. However, that does not take into account the apparent association with radiotherapy. Other cases affecting the vulva, following radical hysterectomy and radiotherapy, were reported. Radiation may induce degenerative changes in the vascular elastic tissue, with subsequent ectasia and secondary epidermal hyperkeratosis. In addition radiation of the pelvic cavity may damage venous blood vessels, compromising the blood return and increasing venous blood pressure, a well known risk factor for the development of angiokeratomas .
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