Clinical presentation
A woman in her late 20s presented to the dermatology clinic for a single irritated, painful lesion on the back, present for many years. On physical examination, there was a 5-mm oval, pink-to-orange papule with an eccentric dark red area located on the lower back (Fig 1).
Fig 1.
Clinical image of lymphangioma. Solitary oval, pink-to-orange papule with an eccentric dark red area, located on the lower back.
Dermatoscopic appearance
Dermatoscopic examination found red-to-purple clods and several 2-color clods with a red crescent-shaped dependent bottom corresponding to blood and a clear to serous color superiorly corresponding to lymph (Fig 2).
Fig 2.
Polarized dermatoscopy shows 2-color clods with a red crescent-shaped bottom (arrows) corresponding to blood and a clear to serous color on top corresponding to lymph.
Histologic diagnosis
Histopathology found proliferations of thin-walled, dilated lymphatics containing pale pink proteinaceous lymph in the upper dermis, with focal hemorrhage within superficial vessels.
Key message.
Lymphangiomas are rare lymphatic malformations that comprise roughly 4% of vascular tumors.1 Typically seen in children, lymphangiomas are subdivided into superficial and deep variants, of which lymphangioma circumscriptum is the most common. They are characterized by clusters of translucent lymph-filled vesicles resembling “frog spawn,” which frequently exhibit extravasated red blood cells.1 Common dermatoscopic findings include red, yellow, or multicolored lacunae, vascular structures, and white lines.1 Two-tone crescent-shaped clods have previously been described in lymphangiomas as hypopyon-like, mimicking the ophthalmologic hypopyon sign of dependent leukocyte sediments in the anterior chamber of the eye.2 In this case of lymphangioma, the designation hyphema-like sign would be more appropriate to describe the crescentic erythrocyte sedimentation, as hyphema classically refers to hemorrhage in the anterior chamber of the eye.2 The hyphema-like sign is a unique dermatoscopic finding to lymphangiomas that can aid in clinical diagnosis.
Footnotes
Funding sources: None.
Conflicts of interest: None disclosed.
References
- 1.Zaballos P., Del Pozo L.J., Argenziano G. Dermoscopy of lymphangioma circumscriptum: a morphological study of 45 cases. Australas J Dermatol. 2018;59(3):e189–e193. doi: 10.1111/ajd.12668. [DOI] [PubMed] [Google Scholar]
- 2.Kumar S., Acharya S., Beuerman R. Deposition of particles on ocular tissues and formation of Krukenberg spindle, hyphema, and hypopyon. J Biomech Eng. 2007;129(2):174–186. doi: 10.1115/1.2472380. [DOI] [PubMed] [Google Scholar]