Dermatologist’s Third Eye as a Diagnostic Clincher in Vascular Nevi

Question A 25-year-old male presented with history of asymptomatic, reddish, flat lesions over the right forearm for the last 2 years. The lesions were initially present over the upper forearm and had progressed to involve the lower forearm up to the right wrist. There was no history of any topical application, trauma, bleeding, or exposure to excessive ultraviolet radiation. There was no history of ocular or neurological symptoms. There was no history of similar lesions elsewhere on the body, in the past, or among family members. There was no history of liver disease, chronic intake of oral medications, chronic illness, or alcoholism. On examination, there were multiple, well-to-ill-defined, erythematous to coppery-red macules and patches with a smooth surface and irregular margins noted over the extensor aspect of the right forearm, as shown in Figure 1. On diascopy, the lesions were nonblanchable. Examination of mucous membranes, hair, and nails and systemic examination were within normal limits. No physical signs of hyperestrogenism were noted. Dermoscopy showed multiple, well-demarcated, distinct round to oval red lagoons, as shown in Figure 2.Figure 1: Erythematous macules coalescing to form patches at places noted over the extensor arm and forearmFigure 2: (a) School of red fish in a pond (b) showing numerous well demarcated round to oval lagoons (blue arrow) in a reddish background in polarized mode of HEINE DELTA20T DERMATOSCOPE (×10)Histopathological examination revealed a near-normal epidermis, with the papillary dermis showing multiple dilated and congested capillaries filled with erythrocytes, without hemorrhage or extravasation of red blood cells, as shown in Figures 3-5. Laboratory investigations, including complete blood count, liver function tests, renal function tests, antinuclear antibody screening, coagulation profile, and serum estrogen levels, were found to be within normal limits.Figure 3: Unremarkable epidermis with papillary dermis showing dilated and congested capillaries (H and E, ×10)Figure 4: Near normal epidermis with multiple dilated and congested capillaries in the papillary dermis with minimal inflammation (H hence, dermoscopy is valuable in differentiating these conditions. Dermoscopy of angioma serpiginosum reveals discrete red lagoons, typically described as a “school of red fish in a pond.”3 The dermoscopic differentials are summarized in Table 1.1,3–5Table 1: Dermoscopic differentials of angioma serpiginosumIn conclusion, although the list of differentials for vascular nevi can be quite extensive, a prompt history – such as trauma favoring acquired port-wine stain or Fegeler syndrome, known associations of unilateral nevoid telangiectasia (e.g. signs of hyperestrogenism, history of alcoholism, or liver disease), subtle clinical cues like an anemic halo in unilateral nevoid telangiectasia, confinement to the head and neck or trigeminal distribution in port-wine stain, and histopathology showing lymphocytes and extravasated erythrocytes in pigmented purpuric dermatosis – can help clinch the diagnosis. Prompt history-taking, careful clinical examination, and histopathology assist in differentiating these conditions to a certain extent, but the dermatologist’s “third eye” in the form of dermoscopy acts as a clincher in distinguishing between different vascular nevi. Isolated lesions of angioma serpiginosum are benign and usually asymptomatic, lacking systemic features. In cases without spontaneous resolution, laser treatment, particularly pulsed dye laser, has proven most effective compared to KTP and IPL lasers.2 Complications, though rare, include bleeding and psychological impacts such as low self-esteem and distress.6 Central nervous system involvement and ocular complications like retinal vein occlusion have been reported only in rare cases of facial and disseminated whole-body lesions.7–10 Angioma serpiginosum generally lacks associations, except for histopathology showing similar vascular changes in a reported case of Goltz syndrome.10 Treatment with pulsed dye laser has shown sustained clearance, though long-term follow-up and relapse reports in untreated patients are lacking.2 In our patient, treatment with pulsed dye laser was advised but declined, as the condition was asymptomatic, benign, and posed only minor cosmetic concern. Authors’ contributions Literature search: CSK; Data acquisition: MV; Manuscript preparation: CSK; Manuscript editing: SK; Manuscript review: EL. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.