Answer B

Cherry angiomas (CAs) are common, asymptomatic, vascular lesions, also known as cherry hemangiomas, Campbell de Morgan spots, and senile angiomas. These lesions affect up to half of adults.1,2 Campbell de Morgan, the surgeon after whom they are named, first described these lesions in 1872.3,4 Tradition holds that de Morgan associated these lesions with cancer. Although the majority of patients with CAs are healthy, eruptive CAs have been associated with melanoma as well as lymphoproliferative disorders.1,5,6

Cherry angiomas usually develop in adults in the fourth or fifth decades of life at a size of approximately 1 mm and continue to increase in number and grow over time up to 5 mm.5,7 These lesions can be identified in 7% of adolescents and 75% of patients older than 75 years.2,5 Risk factors for eruptive CAs include skin tumors and chronic immunosuppression.7 One study found that tamsulosin use is a possible risk factor for CAs whereas clopidogrel had a protective effect against CA development.8 Cherry angiomas also have been reported to be larger in patients with diabetes and to expand more in tropical climates.2 Patients with cerebral cavernous malformations also may present with CAs.5 A case of early-onset CAs in the context of familial nevus flammeus has been reported.5,9 Cherry angiomas have not been shown to affect any race, ethnicity, or sex disproportionately.5

The etiology of CAs is unclear, although several precipitating factors have been suggested such as chemical exposure to 2-butoxyethanol and mustard gas, which can lead to development of multiple CAs.7 Hormones may also be an etiologic factor, as some women develop CAs in pregnancy that regress after delivery.1,5 Genetic mutations in GNAQ and GNA11 also have been linked to CAs. In cases of eruptive CAs, which are extensive and develop acutely, human herpesvirus 8, ramucirumab, lymphoproliferative disorders, and multicentric Castleman disease have been implicated.5 Chronic immunosuppression may be related to CAs, whether iatrogenic or related to aging.7 Cherry angiomas also have been associated with cyclosporine use, liver transplants, and graft vs host disease.2,7

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On physical examination, early lesions may resemble petechiae and appear as flat red macules.2 Later, CAs become multiple, well-demarcated, 1- to 5-mm small bright-red papules. They are most commonly found on the proximal extremities or the trunk, although they may be located on the hands, feet, or face.2,5 Cherry angiomas on the scalp may be less commonly reported because they are asymptomatic and often concealed by hair, making them more challenging to identify.2 CAs typically blanch when pressure is applied but may not if they are fibrotic.5 Some lesions may be polyploid in appearance. Although CAs are primarily asymptomatic, they may bleed after trauma.5

Cherry angiomas are diagnosed clinically according to visual characteristics. Another diagnostic tool is optical coherence tomography, which helps determine the depth and extent of CAs and whether they will respond to laser therapy.5 Histologic examination may help differentiate CAs from conditions that appear similar, especially if there is suspicion of malignancy, in which case they must be removed and sent for histopathologic characterization.2,5

On biopsy, CAs have a thinned epidermis and neovascularized capillaries, with narrow lumens and prominent endothelial cells.2,5 These vessels are arranged in a lobular pattern in the papillary dermis. Between vessels, collagen fibers are edematous and homogenous. The epidermis may be atrophic with loss of rete ridges and peripherally there is an epidermal collarette.5 In later stages of CAs, capillaries begin to dilate and endothelial cells may no longer proliferate.5 The proximity of these dilated and congested capillaries to the atrophic epidermis may explain bleeding of CAs secondary to trauma.2,5

Differential diagnosis of CAs includes acquired tufted hemangioma, lobular capillary hemangioma, pyogenic granuloma, glomeruloid hemangioma, targetoid hemosiderotic hemangioma, angiolymphoid hyperplasia with eosinophilia, and spindle cell hemangioma. Early CAs appear similar to petechiae. Cherry angiomas may also be confused with amelanotic melanoma, which in contrast to CAs are more friable and have malignant potential.5 On the scalp, CAs may appear as macules or papules similar to venous lakes, metastatic carcinoma, angiokeratoma, and pyogenic granuloma, all of which may be differentiated via histopathology.2

Patients may request that CAs be treated for cosmetic purposes or to prevent bleeding after trauma.1,2 Small CAs can be treated with electrodesiccation. Larger lesions may require shave excision.1,5 Additional treatment options include pulsed dye laser (PDL), potassium-titanyl-phosphate (KTP) laser, and Nd:YAG laser, and intense pulsed light.5,10 A study comparing PDL with KTP and electrodesiccation found PDL to be the preferred treatment modality because of decreased procedure-related pain.10 In patients of darker skin types, Nd:YAG laser may be preferable to PDL and KTP, as the latter therapies are associated with an increased risk for pigmentary changes.10 Additional reported treatments include sclerotherapy and cryotherapy.10

Our patient was diagnosed clinically with CAs. He was counseled on the diagnosis and reassured of the benign nature of this condition. He declined treatment for these lesions.

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