Dermoscopy of Angiokeratoma.

A 24-year-old male presented with multiple dark, red-blue-colored hyperkeratotic scrotal papules since childhood [Figure 1]. Dermoscopy [polarized, 10×] revealed red and dark-blue lacunae with a whitish veil [Figure 2]. Although initially reluctant, after seeing the dermoscopic images himself the patient consented for skin biopsy. Histopathology revealed hyperkeratosis and several dilated and congested dermal vessels [Figure 3] confirming a final clinico-dermoscopic-pathological diagnosis of angiokeratoma (AK) of Fordyce.

Figure 1

Multiple dusky-red-blue hyperkeratotic papules clustered over the scrotal skin

Figure 2

Dermoscopy of angiokeratoma revealing multiple dusky-red (yellow arrow), and dark-blue (white arrow) lacunae. Also note the whitish veil that can be appreciated in the upper portion of one lacuna (green arrow) [polarized, ×10]

Figure 3

Dilation of papillary dermal vessels lined by thin endothelial cells and surrounded by sparse perivascular lymphocytic infiltrate. The epidermis shows slight hyperplasia (H and E, ×10)

AKs, classified into five clinical forms constitute a group of vascular ectasias manifesting as solitary or clustered red-blue-colored, hyperkeratotic papules. They may involve the lower limbs, trunk, tongue, scrotum, penile shaft, or labia majora.[1] Our patient was diagnosed as AK of Fordyce owing to scrotal lesions. Despite being clinically diagnostic, evaluation is essential to exclude differentials and allay patient's anxiety. Vascular and pigmented lesions including hemangiomas, pyogenic granuloma (PG), Spitz nevus, and malignant melanoma need differentiation from AK. The characteristic dermoscopic features described for AK include well-demarcated, round lacunae that histologically represent dilated upper dermal vessels and a whitish veil, corresponding to epidermal hyperkeratosis. Dark-blue lacunae indicate vessel thrombosis.[2] Dermoscopy of hemangiomas also show red-bluish lacunae but lack the sharp demarcation seen in AK.[3] PG reveals whitish veils but lacks the red-blue lacunae.[4] The absence of typical red-blue lacunae and presence of dermoscopic hallmarks can differentiate pigmented nevi and melanoma from AK.

This report also emphasizes on an additional non-diagnostic use of dermoscopy in clinical practice, 'dermoscopy-induced skin biopsy' i.e., convincing the patient for a skin biopsy, which is often essential for diagnostic confirmation of many dermatoses.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.