Medscape is available in 5 Language Editions – Choose your Edition here.


Targetoid Hemosiderotic Hemangioma Clinical Presentation

  • Author: J Andrew Carlson, MD; Chief Editor: Dirk M Elston, MD  more...
Updated: Feb 19, 2016


Targetoid hemosiderotic hemangioma (THH) (hobnail hemangioma) is a benign vascular tumor that typically manifests as a small, single lesion on the extremity or trunk of a young to middle-aged adult. It has a variable clinical appearance, but most can be described as annular lesions with a central violaceous papule surrounded by an eccentric ecchymotic ring that can exhibit a targetoid appearance. The wide variation in clinical appearance and variegation of color explains why these lesions can be mistaken for a hemangioma, melanocytic nevus, or melanoma.

Lesions generally are asymptomatic, but they may be painful, change color, increase in size, or exhibit cyclical or episodic change. These changes typically are described as enlargement with deepening of color hue, followed by decrease in size and diminished color intensity.

Cases with cyclical morphologic changes have been correlated with hormonal events of the menstrual cycle, although it should be noted that some of these cases have not been documented rigorously from a microscopic standpoint and can represent other processes such as endometriosis.

Spontaneous regression without scarring has been described with recurrence in 1 of 2 cases reported.[12, 13]



Classic targetoid hemosiderotic hemangioma (THH) manifests as a solitary pigmented lesion consisting of a central, small (2-3 mm), violaceous papule (the bull's-eye) surrounded by an erythematous-to-ecchymotic ring or halo. Overall dimensions can vary from 1-2 cm. Note the image below.

Close-up of a targetoid hemosiderotic hemangioma. Close-up of a targetoid hemosiderotic hemangioma. Note the ectatic vessels (lagoons) in the central violaceous papule.

Lesions typically affect the trunk or the extremities (lower > upper). Head,[1] neck, and oral involvement and the occurrence of 2 simultaneous lesions have been reported.

The typical clinical morphology consists of a macule, papule, or targetlike lesion. Targetoid lesions are more likely to be seen in larger and symptomatic targetoid hemosiderotic hemangiomas, while macular targetoid hemosiderotic hemangioma lesions typically are small.

A central papule is common but is not present universally. The peripheral halo can wax and wane in both size and color as a result of the degree of erythrocyte extravasation and hemosiderin deposition. The predominant color is brown or tan; a few lesions exhibit a black, violaceous, or grayish appearance.

Variability in clinical morphology results in a wide variety of clinical diagnoses, including considerations such as KS, melanocytic nevus, or melanoma.

Dermoscopic examination reveals sharply demarcated red or reddish-blue round and oval structures. Intermixed with these structures are smaller, pale pink, round structures found among a diffuse pink-white pigmentation. These 2 regions are thought to correspond to ecstatic thin-walled vessels of the papillary dermis and slitlike vascular spaces of the reticular dermis, respectively. A few sharply demarcated black macules representing hemorrhagic crusts can also be found.[9]

If serially monitored dermoscopically, a violaceous, expanding ring can be found surrounding the central vascular dilations. This ring becomes an erythematous or hypopigmented halo that eventually fades. Fine delicate pigmentation corresponding to hemosiderin can be found in this halo region.[13, 14, 15]

Pigment networks (ie, brown or black globules or dots) typical of melanocytic proliferations are not found in targetoid hemosiderotic hemangiomas.



Trauma is the only known predisposing factor for targetoid hemosiderotic hemangioma (THH).[16, 17] Reports of targetoid hemosiderotic hemangioma secondary to irritation from a belt and arthropod assaults exist. Histologic findings of foreign body giant cell reaction in a few cases points to a preceding injury. Episodic changes of enlarging and diminishing hemorrhagic/hemosiderotic halo also implicate recurring trauma or vessel fragility.

Hormones can influence clinical morphology, resulting in the cyclic changes of waxing and waning diameter and peripheral color. Estrogen is believed to mediate pregnancy-related vessel changes, such as spider telangiectases, and estrogen is known to promote vascular permeability and fragility, venous distensibility, increased blood flow, and vasomotor instability.[18] In targetoid hemosiderotic hemangioma, fluctuating estrogen levels may result in vessel instability and leakage. Of note, hormonal receptors have not been identified histologically in lesions of targetoid hemosiderotic hemangioma noted to cyclically change with the menstrual cycle.

Contributor Information and Disclosures

J Andrew Carlson, MD Professor, Director of Dermatopathology, Department of Pathology, Division of Dermatopathology, Albany Medical College

J Andrew Carlson, MD is a member of the following medical societies: American Academy of Dermatology, International Society of Dermatopathology, American Society of Dermatopathology, International Academy of Pathology, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.


Herbert P Goodheart, MD Associate Clinical Professor, Department of Dermatology, Mount Sinai Hospital, New York, New York

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Society for Investigative Dermatology, Association of Professors of Dermatology, North American Hair Research Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Timothy McCalmont, MD Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology

Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, United States and Canadian Academy of Pathology

Disclosure: Received consulting fee from Apsara for independent contractor.

  1. Santa Cruz DJ, Aronberg J. Targetoid hemosiderotic hemangioma. J Am Acad Dermatol. 1988 Sep. 19(3):550-8. [Medline].

  2. Carlson JA, Daulat S, Goodheart HP. Targetoid hemosiderotic hemangioma- a dynamic vascular tumor: report of 3 cases with episodic and cyclic changes and comparison with solitary angiokeratomas. J Am Acad Dermatol. 1999 Aug. 41(2 Pt 1):215-24. [Medline].

  3. Joyce JC, Keith PJ, Szabo S, Holland KE. Superficial hemosiderotic lymphovascular malformation (hobnail hemangioma): a report of six cases. Pediatr Dermatol. 2014 May-Jun. 31 (3):281-5. [Medline].

  4. Trindade F, Kutzner H, Tellechea Ó, Requena L, Colmenero I. Hobnail hemangioma reclassified as superficial lymphatic malformation: a study of 52 cases. J Am Acad Dermatol. 2012 Jan. 66(1):112-5. [Medline].

  5. Al Dhaybi R, Lam C, Hatami A, Powell J, McCuaig C, Kokta V. Targetoid hemosiderotic hemangiomas (hobnail hemangiomas) are vascular lymphatic malformations: a study of 12 pediatric cases. J Am Acad Dermatol. 2012 Jan. 66(1):116-20. [Medline].

  6. AbuHilal M, Breslavet M, Ho N, Taylor G, Pope E. Hobnail Hemangioma (Superficial Hemosiderotic Lymphovascular Malformation) in Children: A Series of 6 Pediatric Cases and Review of the Literature. J Cutan Med Surg. 2015 Oct 16. [Medline].

  7. Folpe AL, Veikkola T, Valtola R, Weiss SW. Vascular endothelial growth factor receptor-3 (VEGFR-3): a marker of vascular tumors with presumed lymphatic differentiation, including Kaposi's sarcoma, kaposiform and Dabska-type hemangioendotheliomas, and a subset of angiosarcomas. Mod Pathol. 2000 Feb. 13(2):180-5. [Medline].

  8. Martin RA, Howard FM Jr, Salamone CR, Reese DF. Spinal cord vascular malformations with symptoms during menstruation. Report of two cases. J Neurosurg. 1977 Oct. 47(4):626-9. [Medline].

  9. Morganroth GS, Tigelaar RE, Longley BJ, Luck LE, Leffell DJ. Targetoid hemangioma associated with pregnancy and the menstrual cycle. J Am Acad Dermatol. 1995 Feb. 32(2 Pt 1):282-4. [Medline].

  10. Ortiz-Rey JA, Gonzalez-Ruiz A, San Miguel P, Alvarez C, Iglesias B, Anton I. Hobnail haemangioma associated with the menstrual cycle. J Eur Acad Dermatol Venereol. 2005 May. 19(3):367-9. [Medline].

  11. Fernandez-Flores A, Manjon AJ, Campo F. Clinical changes in "true" hobnail hemangioma during menstruation. Bratisl Lek Listy. 2008. 109(3):141-3. [Medline].

  12. Tan C, Zhu WY, Lai RS. A recurrent case of targetoid hemosiderotic haemangioma. Acta Derm Venereol. 2008. 88(2):181-2. [Medline].

  13. Ghibaudo N, Lacour JP, Argenziano G, Ortonne JP, Bahadoran P. Fully regressive targetoid haemosiderotic haemangioma. J Eur Acad Dermatol Venereol. 2009 Jun. 23(6):722-3. [Medline].

  14. Morales-Callaghan AM, Martinez-Garcia G, Aragoneses-Fraile H, Miranda-Romero A. Targetoid hemosiderotic hemangioma: clinical and dermoscopical findings. J Eur Acad Dermatol Venereol. 2007 Feb. 21(2):267-9. [Medline].

  15. Sahin MT, Demir MA, Gunduz K, Ozturkcan S, Turel-Ermertcan A. Targetoid haemosiderotic haemangioma: dermoscopic monitoring of three cases and review of the literature. Clin Exp Dermatol. 2005 Nov. 30(6):672-6. [Medline].

  16. Adams BB, Lucky AW. Acquired port-wine stains and antecedent trauma: case report and review of the literature. Arch Dermatol. 2000 Jul. 136(7):897-9. [Medline].

  17. Christenson LJ, Stone MS. Trauma-induced simulator of targetoid hemosiderotic hemangioma. Am J Dermatopathol. 2001 Jun. 23(3):221-3. [Medline].

  18. Beale C, Collins P. Estrogen and cardiovascular dynamics. Semin Reprod Endocrinol. 1996 Feb. 14(1):71-7. [Medline].

  19. Krahl D, Petzoldt D. [Target-like hemosiderotic hemangioma. Further differential diagnosis of Kaposi sarcoma]. Hautarzt. 1994 Jan. 45(1):34-7. [Medline].

  20. Mu XC, Tran TA, Dupree M, Carlson JA. Acquired vulvar lymphangioma mimicking genital warts. A case report and review of the literature. J Cutan Pathol. 1999 Mar. 26(3):150-4. [Medline].

  21. Patrizi A, Giacomini F, Savoia F, Misciali C, Neri I. Targetoid hemosiderotic naevus. J Eur Acad Dermatol Venereol. 2009 Apr. 23(4):493-4. [Medline].

  22. Cossu S, Satta R, Cottoni F, Massarelli G. Lymphangioma-like variant of Kaposi's sarcoma: clinicopathologic study of seven cases with review of the literature. Am J Dermatopathol. 1997 Feb. 19(1):16-22. [Medline].

  23. Zaballos P, Llambrich A, Del Pozo LJ, Landi C, Pizarro A, Vera A, et al. Dermoscopy of Targetoid Hemosiderotic Hemangioma: A Morphological Study of 35 Cases. Dermatology. 2015. 231 (4):339-44. [Medline].

  24. Pabuccuoglu U, Ozkara E, Lebe B. Hobnail haemangioma occurring on the nasal dorsum. Br J Dermatol. 2002 Jan. 146(1):162-4. [Medline].

  25. Gutzmer R, Kaspari M, Herbst RA, Kapp A, Kiehl P. Absence of HHV-8 DNA in hobnail hemangiomas. J Cutan Pathol. 2002 Mar. 29(3):154-8. [Medline].

  26. Cheuk W, Wong KO, Wong CS, Dinkel JE, Ben-Dor D, Chan JK. Immunostaining for human herpesvirus 8 latent nuclear antigen-1 helps distinguish Kaposi sarcoma from its mimickers. Am J Clin Pathol. 2004 Mar. 121(3):335-42. [Medline].

Most targetoid hemosiderotic hemangiomas do not exhibit a targetoid appearance. An older waning lesion is presented showing a 2-toned papule with a dark brown center surrounded by a tan-brown rim. This clinical image can be confused with a melanocytic nevus or dermatofibroma. This 20-year-old patient described episodic changes that varied from a larger violaceous papule surrounded by an erythematous halo (target lesion) to the illustrated lesion.
Targetoid hemosiderotic hemangiomas are biphasic vascular tumors that show superficial telangiectases, often lined by hobnailed endothelial cells and deeper slitlike vascular spaces. Note the solitary angiokeratomalike change: the irregular epidermal hyperplasia overlying numerous, blood-filled, dilated vascular spaces in which the lumens diminish with descent into the subjacent dermis (hematoxylin and eosin, original magnification X40).
Siderophages and extravasated red blood cells are located at the periphery and between the deep dissecting vascular spaces of targetoid hemosiderotic hemangioma. Prussian blue stain for iron outlines the margins and highlights abundant hemosiderin deposition (Prussian blue, original magnification X100).
Targetoid hemosiderotic hemangioma mimicking nodular malignant melanoma. Note the dark black papule surrounded by a faint brown rim.
Histologically, targetoid hemosiderotic hemangioma (hobnail hemangioma) can mimic both malignant processes (low-grade angiosarcoma variants) and cutaneous manifestations of systemic disease (Kaposi sarcoma in AIDS). In this instance, the promontory sign of Kaposi sarcoma is replicated by targetoid hemosiderotic hemangioma. Lymphangiectases envelop an arteriole and are surrounded by dilated blood-filled telangiectases (hematoxylin and eosin, original magnification X200).
Close-up of a targetoid hemosiderotic hemangioma. Note the ectatic vessels (lagoons) in the central violaceous papule.
Solitary angiokeratoma with an erythematous halo (as compared to early targetoid hemosiderotic hemangioma). Histologically, this lesion was found to have deposition of hemosiderin, extravasated red blood cells, lymphangiectases, and focally small slitlike vascular spaces in the reticular dermis similar to that of targetoid hemosiderotic hemangioma.
Hobnailed or protuberant endothelial cells characteristic of the superficial vessels of targetoid hemosiderotic hemangiomas. Note the extravasated red blood cells next to the empty and ectatic vascular spaces (hematoxylin and eosin, original magnification X400).
Dissecting or pseudoangiosarcomatous vascular spaces of targetoid hemosiderotic hemangioma. Note the absence of marked cytologic atypia and the overlap of endothelial cells that is expected for angiosarcoma (hematoxylin and eosin, original magnification X200).
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.