Lymphangioma circumscriptum treated with radiofrequency ablation.

Lymphangioma circumscriptum (LC), a hamartomatous lymphatic malformation, is a therapeutic challenge for the dermatologist. Various modalities like surgical excision, lasers, and sclerotherapy have been used in the past to treat this notorious skin condition. We report the efficacy of a radiofrequency ablation in a patient with LC. The treatment efficacy of radiofrequency was satisfactory in our patient with no recurrence during 1 year follow-up period. The radiofrequency technique is a safe and economic treatment for management of LC.

Introduction

Lymphangioma circumscriptum (LC) or microcystic lymphatic malformation is a hamartomatous malformation of the lymphatic channels of the skin. Treatment of LC is difficult because of the persistent nature of the disease due to deeper subcutaneous cisternal connections. We report here a case of LC treated effectively with radiofrequency ablation without any recurrence.

Case Report

A 16-year-old male with Fitzpatrick skin type V presented to our clinic with partially fluid-filled lesions on left upper arm with slight local swelling. The patient had these lesions since the age of 2 years and had been repeatedly treated with antibiotics for local infection. Examination showed a well-defined plaque on left upper arm with grouped vesicular lesions, giving the typical appearance of a “frog spawn” and slight localized swelling. There was no other dermatologic or systemic abnormality. There was no family history of similar lesions.

A clinical diagnosis of LC was made. A biopsy was taken from the edge of the lesion and histopathology showed multiple thin-walled, dilated lymphatic spaces in the papillary dermis and these spaces contained lymph and few erythrocytes. The overlying epidermis was thin, and there were elongated rete ridges that appeared to surround the lymphatic channels. The findings were consistent with the clinical diagnosis.

The patient was given a systemic antiobiotic, cefadroxil 500 mg twice daily for 5 days, to treat the infection including oozing from the lesions and to decrease the inflammation. Radiofrequency ablation was done a week later (Basco radiofrequency device, Model RF-B2, high frequency 2 MHz, power <150 W), in cut and coagulate mode with wire loop electrode, under local anesthesia. The wound was dressed using a sterile paraffin pad. The patient was advised to clean the area with betadine lotion and apply topical antibiotic mupirocin on the lesions. Three sessions were required at weekly intervals for the lesions to clear as some deeper components were left untreated at the first two sessions. All the lesions were successfully ablated at third session. One week after last treatment, the area had partially healed with slight depigmentation. At 1 month, the lesions had completely healed and swelling had subsided [Figure 1]. The depigmentation resolved completely at the end of 3 months. There were no side effects of the treatment. Patient was called for monthly follow up. No recurrence has occurred in the past 1 year and the patient is still under surveillance.

Figure 1

(a) LC lesion on the left upper arm; (b) lesions being treated with radiofrequency ablation; (c) immediate post treatment red erythematous area; (d) complete healing of the lesions at 1 month

Discussion

LC is benign ectasia with two components: the clinically obvious, dermal vesicular component, visible on the skin, and the deeper subcutaneous cisternal element.[1] Whimster described the pathogenesis and said that LC arises from the subcutaneous muscle-coated lymphatic cisterns which receive lymphatic flow from the surrounding tissue, but this is not drained to the normal lymphatic system.[2] These dilated cisterns conduct the lymph through communicating channels into the dermal thin lymphatics, which balloon out into the epidermis. Treatment modalities include surgical excision, lasers and sclerotherapy with varying success.[3-5] We tried the radiofrequency ablation to treat LC, which produced near-complete clinical ablation with coagulation of lesional and perilesional skin leading to fibrosis of the perivesicular lymphatics. Omprakash et al. reported palliative coagulation of LC using radiofrequency current in two cases. They did the follow up for 6 months, which showed no recurrence.[6] They used the coagulation mode only. We, however, used the cut and coagulate mode. The follow up was longer in our case, i.e., 1 year and we are encouraged to do a case series to determine the efficacy of radiofrequency in this notorious condition. This case is being reported to emphasize the importance of radiofrequency treatment in LC. Large-scale studies will have to be carried out to ensure the efficacy.