Targetoid Hemosiderotic Hemangioma Clinical Presentation

Updated: Mar 05, 2018
  • Author: J Andrew Carlson, MD; Chief Editor: Dirk M Elston, MD  more...
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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]


Physical Examination

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, 17, 18]

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