Bright Red, Dome-Shaped Papules - Clinical Advisor

Bright Red, Dome-Shaped Papules

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A 62-year-old man with gastric adenocarcinoma for which he has been receiving chemotherapy for 4 weeks presents to his internist with new lesions on his trunk. He noticed approximately 30 bright red, smooth, dome-shaped papules measuring 2 to 5 mm that appeared suddenly on his arms, chest, and back. He denies any other recent illnesses or fevers. The patient is concerned that the spots are a sign that his cancer is worsening. Punch biopsy is obtained, revealing erythrocytes filling endothelial cell-lined dilated vascular channels in the mid to upper dermis.

Cherry angiomas are also known as Campbell de Morgan spots, cherry hemangiomas, and senile angiomas. These lesions are the most common benign vascular tumors affecting primarily older, pale-skinned individuals.1,2 Cherry angiomas are well-demarcated, blanchable, bright red, dome-shaped papules and pinpoint...

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Cherry angiomas are also known as Campbell de Morgan spots, cherry hemangiomas, and senile angiomas. These lesions are the most common benign vascular tumors affecting primarily older, pale-skinned individuals.1,2 Cherry angiomas are well-demarcated, blanchable, bright red, dome-shaped papules and pinpoint macules most commonly found on the trunk and arms measuring several millimeters in diameter.1 The number and size of lesions increase with age with prevalence increasing from approximately 5% in adolescents to approximately 75% in adults aged >75 years.1,2 Diagnosis is based on patient history and clinical presentation. Lesions do not require treatment although several cosmetic therapies exist.

The etiology and pathogenesis of cherry angiomas are poorly understood.1,2 For a time it was even unclear if these lesions should be classified as vascular tumors or vascular malformations. Recent studies have shown the cytoplasmic expression of Wilms tumor protein 1, a marker of endothelial plasticity, in cherry angioma tumor cells.3 This evidence thus classifies cherry angiomas as vascular tumors given the proliferative nature of the contained endothelial cells. Other studies have attempted to discover somatic mutations associated with cherry angiomas. One such study found that mutations in genes GNAQ and GNA11 were found to be present in 50% of cherry angioma samples taken (n=10); these are the same mutations present in port wine stains and Sturge-Weber syndrome.4 Of note, pathogenesis of cherry angiomas may be associated with malignancy as sudden appearance is often associated with systemic internal malignancy.3

Several risk factors for the development of cherry angiomas exist. Lesions are most commonly found in the third to fourth decade of life in pale-skinned individuals.1,3 A cross-sectional study found older age, chronic immunosuppression, skin tumors, and nonskin tumors to have an increased association with the appearance of cherry angiomas.2 In addition, the appearance of cherry angiomas has been associated with pregnancy, human herpesvirus 8, chronic graft-vs-host disease, and chemical compounds including mustard gas, bromides, and cyclosporine.1,2

Cherry angiomas typically present in an eruptive fashion on the upper extremities and trunk.1,2 Lesions can be found on any skin surface but are  found less commonly on the hands, feet, face, and open space mucosal surfaces.1,3 Cherry angioma can also arise as a singular lesion or in fewer numbers; this presentation is more commonly associated with earlier onset and genetic predisposition.2

Important considerations for the differential diagnosis include petechiae, pyogenic granulomas, amelanotic melanomas, strawberry hemangioma, Kaposi sarcoma, and bacillary angiomatosis.1,5 Petechiae arise due to bleeding under the skin in the context of low platelet levels. Pyogenic granulomas typically are benign skin or mucosal-vascular tumors that grow rapidly and bleed profusely after minimal injury, usually with a more friable appearance and lobular pattern than cherry angiomas.5,6 An amelanotic melanoma has the features of melanoma without the typical pigmentation; thus, irregular borders and large size should help distinguish it from cherry angioma. Strawberry hemangiomas, or capillary hemangiomas, arise in infants and regress with age. Kaposi sarcoma and bacillary angiomatosis often are associated with immunosuppression due to infection with human herpesvirus 8 and Bartonella henselae, respectively.

In cases when diagnosis cannot be made based on presentation and history, histologic analysis typically is recommended. When malignancy is suspected, excision of the lesion prior to histologic analysis is preferred. Histologically, cherry angiomas are true capillary hemangiomas, consisting of an amalgamation of newly formed capillaries within the papillary dermis.1 Intravascular changes such as hyalinization of collagen fibers and edema can also be seen.1,3

Cherry angiomas do not require treatment since they are self-limited, non-life-threatening, and can be managed with observation. However, patients may choose to treat these lesions for cosmetic purposes. Currently, no existing medical therapies exist; however, several surgical options ranging from destructive treatments to less-invasive targeted laser therapies are available. Destructive treatments include shave excision and electrodesiccation and curettage.1 Invasive targeted laser therapies are also quite effective since cherry angiomas contain oxygenated hemoglobin, which can be targeted and vaporized with laser wavelengths of 418, 542, and 577 nm.7 Cherry angiomas are destroyed when the vascular lumen is obliterated. Pulsed-dye laser as well as potassium titanyl phosphate laser have been shown to minimize risk of treatment-associated textural change or scarring.8

The patient in this case was reassured that these spots were cherry angiomas and likely related to his continued immunosuppression. These lesions were unlikely a sign that his cancer was worsening. The spots themselves were benign lesions that did not affect his mortality and did not require immediate medical or surgical treatment. The patient deferred elective management.

Junru Yan, BA, is a medical student; McKenna E. Boyd, BS, is a medical student; and Christopher Rizk, MD, is a dermatology fellow at Baylor College of Medicine, in Houston, Texas.

References

  1. Kim JH, Park HY, Ahn SK. Cherry angiomas on the scalp. Case Rep Dermatol. 2009;1(1):82-86.
  2. Borghi A, Minghetti S, Battaglia Y, Corazza M. Predisposing factors for eruptive cherry angiomas: new insights from an observational study. Int J Dermatol. 2016;55(11):e595-e608.
  3. Fernandez-Flores A, Colmenero I. Campbell de Morgan spots (cherry angiomas) show endothelial proliferation. Am J Dermatopath. 2018;40(12):894-898.
  4. Klebanov N, Lin WM, Artomov M, et al. Use of targeted next-generation sequencing to identify activating hot spot mutations in cherry angiomas. JAMA Dermatol. 2019;155(2):211-215.
  5. Cheah S, Dekoven J. Pyogenic granuloma complicating pulsed-dye laser therapy for cherry angioma. Australas J Dermatol. 2009;50(2):141-143.
  6. Bovée JVMG. Practical soft tissue pathology: a diagnostic approach.  Virchows Arch. 2018;473(6):785-786.
  7. Rohrer TE, Geronemus RG, Berlin AL. Vascular lesions. In: Goldberg DJ, ed. Laser and Lights, Volume 1. 2nd ed. Philadelphia, PA: Saunders Elsevier: 2009.
  8. Collyer J, Boone SL, White LE, et al. Comparison of treatment of cherry angiomata with pulsed-dye laser, potassium titanyl phosphate laser, and electrodesiccation.Arch Dermatol. 2010;146(1):33-37.
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