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Case Report  |   February 2011
Recurrent Targetoid Hemosiderotic Hemangioma in a 26-Year-Old Man
Author Notes
  • From the Department of Aviation Medicine at the Naval Hospital Oak Harbor in Washington. 
  • Address correspondence to LT Sarah B. Gendernalik, DO, MC (FS), USN, Department of Aviation Medicine, Naval Hospital Oak Harbor, 3475 N Saratoga St, Oak Harbor, WA 98278-4927. E-mail: sarah.gendernalik@med.navy.mil 
Article Information
Cardiovascular Disorders
Case Report   |   February 2011
Recurrent Targetoid Hemosiderotic Hemangioma in a 26-Year-Old Man
The Journal of the American Osteopathic Association, February 2011, Vol. 111, 117-118. doi:10.7556/jaoa.2011.111.2.117
The Journal of the American Osteopathic Association, February 2011, Vol. 111, 117-118. doi:10.7556/jaoa.2011.111.2.117
Abstract

A 26-year-old previously healthy man presented with a 6-mm violaceous papule that had a surrounding 1.5-cm annular, nonblanching, erythematous halo on the right-sided flank. The man reported the lesion had been recurring for 4 to 5 years, flaring every 4 to 5 months and then slowly disappearing until the cycle recurred. Targetoid hemosiderotic hemangioma was clinically diagnosed. The lesion was removed by means of elliptical excision and the condition resolved. The authors discuss the clinical appearance, histology, and etiology of targetoid hemosiderotic hemangiomas.

Targetoid hemosiderotic hemangiomas (THHs) are a commonly misdiagnosed presentation encountered in the primary care setting. In the present case report, we aim to provide general practitioners with an understanding of the clinical appearance, pathology, and prognosis of THH. 
Report of Case
A 26-year-old previously healthy man presented to our primary care clinic with a 6-mm violaceous papule with a surrounding 1.5-cm annular, nonblanching, erythematous halo on the rightsided flank (Figure). The patient stated that the lesion had been recurring for 4 to 5 years, flaring intermittently every 4 to 5 months and then slowly disappearing until the cycle recurred. The patient noted the lesion typically developed a red ring around it and itched and burned each time it developed. The lesion faded completely to normal-appearing skin between episodes, without evidence of a papule or postinflammatory hyperpigmentation. The patient had sought medical treatment in the past, but each time, the lesion had resolved before he was able to see a physician. The day he presented to the clinic was the first appointment he was able to secure during the acute phase of the lesion's cycle. The patient was diagnosed clinically as having THH, or hobnail hemangioma, which is a rare benign solitary vascular tumor.1,2 The lesion was removed by means of elliptical excision and the THH was resolved. 
Figure.
A 6-mm violaceous papule with a surrounding 1.5-cm annular, nonblanching, erythematous halo in a 26-year-old man.
Figure.
A 6-mm violaceous papule with a surrounding 1.5-cm annular, nonblanching, erythematous halo in a 26-year-old man.
 
Comment
A THH lesion can develop anywhere on the body but most frequently occurs on the trunk and extremities. The tumor typically develops in patients aged 7 to 55 years2,3 and has a male to female incidence of 1 to 1.4 Patients with THH often present with acute onset of a violaceous papule or nodule with a transient ecchymotic halo,1 which gives the lesion the targetoid appearance. Over time, the halo may expand peripherally and become swollen and tender, eventually disappearing and leaving only the central papule.2 The duration of THH ranges from 1 week to 2 decades.4 As in the present case, THH is often recurrent or episodic in nature until excision. The lesion is often misdiagnosed as a melanocytic nevus, hemangioma, Kaposi sarcoma, or dermatofibroma. 
Targetoid hemosiderotic hemangioma can be determined from other vascular lesions by means of clinicopathologic correlation.3 Histologically, THH is characterized by a dermal vascular proliferation, specifically prominent, dilated, thin-walled vessels in the papillary dermis.4,5 Prominent endothelial cells create a “hobnail” appearance.4 Erythrocyte extravasation and hemosiderin deposition are often present and may cause the halo appearance.1 
Etiologies of THH have been discussed in the literature and vary widely. Many researchers believe this lesion to be a reactive process, resulting from trauma to a pre-existing hemangioma or lymphangioma.5 Lesions have also been known to demonstrate clinical variations during the menstrual cycle and pregnancy.3,6 However, given the equal incidence of THH in men and women, hormonal influence is likely a contributing rather than causal factor in THH etiology. One case report4 suggests familial predilection or similar environmental exposure may be a factor in the development of THH. 
Although THH is a benign vascular proliferation, it can be removed for diagnostic or cosmetic purposes. Excision after the lesion has partially regressed may improve cosmesis.1 
Conclusion
When encountering a violaceous papule or nodule in the primary care setting, physicians should include THH in their differential diagnosis. 
 The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States government.
 
 Financial Disclosures: None reported.
 
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