Clinical Challenge
Pink Nodule with a Peculiar Pattern on Trichoscopy
INTRODUCTION
A 35‑year‑old male presented with a swelling over scalp since 1 year. Initially, it was about a pea size, which gradually progressed to attain the present size. There was no history of preceding trauma to the site. He complained of bleeding from the lesion while combing. Examination revealed a single, sessile, erythematous nodule measuring 1 × 1 cm with lobulated surface located over parietal region of scalp [Figure 1]. Systemic examination and blood investigation were unremarkable. Dermoscopic examination revealed homogeneous erythematous areas intercepted with yellowish white rail lines. Bright red line corresponding to vascular structures are also seen [Figure 2].
Figure 1: Erythematous nodule with lobulated surface
Excision biopsy was performed and sent for histopathological study. The epidermis was flattened and dermis showed dilated and congested capillaries with edematous stroma [Figure 3]. WHAT IS YOUR DIAGNOSIS?
Answer Pyogenic granuloma (PG) (Lobular capillary hemangioma). DISCUSSION
The standard methods used to diagnose scalp and hair disorders like inspection, hair pull, or biopsy vary in sensitivity, reproducibility, and invasiveness. Dermoscopy of hair also called as trichoscopy, is a non invasive tool which helps us to observe surface and subsurface structures and provide novel diagnostic patterns. Various trichoscopy patterns have been studied, which help in diagnosis of hair disease and nontumoral scalp disorders.[1] However, there is paucity of trichoscopy studies in benign and malignant tumors of scalp.
Figure 2: Dermoscopy shows homogeneous erythematous areas (yellow star) with white rail lines (black diamond) and vascular structures (black star)
Access this article online Quick Response Code Website: www.ijtrichology.com
DOI: 10.4103/0974-7753.125621
International Journal of Trichology / Jul-Sep 2013 / Vol-5 / Issue-3
Figure 3: Shows multiple, dilated and congested capillaries and edematous stroma (H and E, ×10) and close up view (H and E, ×40; inset) 161
Ankad, et al.: Pink nodule with a peculiar pattern on trichoscopy
PG is a common vascular proliferation of skin and mucous membranes affecting all age groups and more commonly men.[2,3] It presents as a solitary, rapidly growing, papule or polyp that bleeds easily after minor trauma.[4‑6] It is very important to confirm the diagnosis by microscopy. Dermoscopy can aide in preoperative diagnosis of this benign tumor. Seven exclusive patterns were made up from the combination of the structures observed like ‘reddish homogeneous area’ (RHA) histologically corresponding to presence of numerous small capillaries or proliferating vessels, ‘white collarette’ (WC) corresponds to the hyperplastic adnexal epithelium that partially or totally embraces the lesion at the periphery, ‘white rail lines’ (WRL) correspond histologically to the fibrous septa that surround the capillary tufts and ‘vascular structures’ (VS). The pattern composed of RHA, WC, and WRL in the absence of VS has been demonstrated to be 100% specific for pyogenic granulomas in one study.[7] To conclude, PG is a benign tumor rarely affecting scalp and hence can be confused with various benign and malignant tumors of scalp and trichoscopy, although not a substitute for histology, can help in confirming the diagnosis.
Balachandra S Ankad, Savitha L Beergouder, Masroor A Shaik
Department of Dermatology, Siddavanahalli Nijalingappa Medical College, Navanagar, Bagalkot ‑ 587 102, Karnataka, India. E‑mail: [email protected] REFERENCES 1. Tosti A, Ross EK. Patterns of scalp and hair disease revealed by videodermoscopy. In: Tosti A, editor. Dermoscopy of Hair and Scalp Disorders. 1st ed. London: Informa Healthcare; 2007. p. 1‑14. 2. Calonj E. Soft‑tissue tumors and tumour‑like conditions. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology. 8th ed. Malden: Blackwell; 2010. p. 56.25. 3. Harris MN, Desai R, Chuang TY, Hood AF, Mirowski GW. Lobular capillary hemangiomas: An epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol 2000;42:1012‑6. 4. Fortna RR, Junkins‑Hopkins JM. A case of lobular capillar y hemangioma (pyogenic granuloma), localized to the subcutaneous tissue, and a review of the literature. Am J Dermatopathol 2007;29:408‑11. 5. Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997;37:887‑919. 6. Demir Y, Demir S, Aktepe F. Cutaneous lobular capillary hemangioma induced by pregnancy. J Cutan Pathol 2004;31:77‑80. 7. Zaballos P, Carulla M, Ozdemir F, Zalaudek I, Bañuls J, Llambrich A, et al. Dermoscopy of pyogenic granuloma: A morphological study. Br J Dermatol 2010;163:1229‑37. How to cite this article: Ankad BS, Beergouder SL, Shaik MA. Pink nodule with a peculiar pattern on Trichoscopy. Int J Trichol 2013;5:161-2.
New features on the journal’s website Optimized content for mobile and hand-held devices HTML pages have been optimized of mobile and other hand-held devices (such as iPad, Kindle, iPod) for faster browsing speed. Click on [Mobile Full text] from Table of Contents page. This is simple HTML version for faster download on mobiles (if viewed on desktop, it will be automatically redirected to full HTML version) E-Pub for hand-held devices EPUB is an open e-book standard recommended by The International Digital Publishing Forum which is designed for reflowable content i.e. the text display can be optimized for a particular display device. Click on [EPub] from Table of Contents page. There are various e-Pub readers such as for Windows: Digital Editions, OS X: Calibre/Bookworm, iPhone/iPod Touch/iPad: Stanza, and Linux: Calibre/Bookworm. E-Book for desktop One can also see the entire issue as printed here in a ‘flip book’ version on desktops. Links are available from Current Issue as well as Archives pages. Click on View as eBook 162
International Journal of Trichology / Jul-Sep 2013 / Vol-5 / Issue-3
Copyright of International Journal of Trichology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Pink Nodule with a Peculiar Pattern on Trichoscopy
INTRODUCTION
A 35‑year‑old male presented with a swelling over scalp since 1 year. Initially, it was about a pea size, which gradually progressed to attain the present size. There was no history of preceding trauma to the site. He complained of bleeding from the lesion while combing. Examination revealed a single, sessile, erythematous nodule measuring 1 × 1 cm with lobulated surface located over parietal region of scalp [Figure 1]. Systemic examination and blood investigation were unremarkable. Dermoscopic examination revealed homogeneous erythematous areas intercepted with yellowish white rail lines. Bright red line corresponding to vascular structures are also seen [Figure 2].
Figure 1: Erythematous nodule with lobulated surface
Excision biopsy was performed and sent for histopathological study. The epidermis was flattened and dermis showed dilated and congested capillaries with edematous stroma [Figure 3]. WHAT IS YOUR DIAGNOSIS?
Answer Pyogenic granuloma (PG) (Lobular capillary hemangioma). DISCUSSION
The standard methods used to diagnose scalp and hair disorders like inspection, hair pull, or biopsy vary in sensitivity, reproducibility, and invasiveness. Dermoscopy of hair also called as trichoscopy, is a non invasive tool which helps us to observe surface and subsurface structures and provide novel diagnostic patterns. Various trichoscopy patterns have been studied, which help in diagnosis of hair disease and nontumoral scalp disorders.[1] However, there is paucity of trichoscopy studies in benign and malignant tumors of scalp.
Figure 2: Dermoscopy shows homogeneous erythematous areas (yellow star) with white rail lines (black diamond) and vascular structures (black star)
Access this article online Quick Response Code Website: www.ijtrichology.com
DOI: 10.4103/0974-7753.125621
International Journal of Trichology / Jul-Sep 2013 / Vol-5 / Issue-3
Figure 3: Shows multiple, dilated and congested capillaries and edematous stroma (H and E, ×10) and close up view (H and E, ×40; inset) 161
Ankad, et al.: Pink nodule with a peculiar pattern on trichoscopy
PG is a common vascular proliferation of skin and mucous membranes affecting all age groups and more commonly men.[2,3] It presents as a solitary, rapidly growing, papule or polyp that bleeds easily after minor trauma.[4‑6] It is very important to confirm the diagnosis by microscopy. Dermoscopy can aide in preoperative diagnosis of this benign tumor. Seven exclusive patterns were made up from the combination of the structures observed like ‘reddish homogeneous area’ (RHA) histologically corresponding to presence of numerous small capillaries or proliferating vessels, ‘white collarette’ (WC) corresponds to the hyperplastic adnexal epithelium that partially or totally embraces the lesion at the periphery, ‘white rail lines’ (WRL) correspond histologically to the fibrous septa that surround the capillary tufts and ‘vascular structures’ (VS). The pattern composed of RHA, WC, and WRL in the absence of VS has been demonstrated to be 100% specific for pyogenic granulomas in one study.[7] To conclude, PG is a benign tumor rarely affecting scalp and hence can be confused with various benign and malignant tumors of scalp and trichoscopy, although not a substitute for histology, can help in confirming the diagnosis.
Balachandra S Ankad, Savitha L Beergouder, Masroor A Shaik
Department of Dermatology, Siddavanahalli Nijalingappa Medical College, Navanagar, Bagalkot ‑ 587 102, Karnataka, India. E‑mail: [email protected] REFERENCES 1. Tosti A, Ross EK. Patterns of scalp and hair disease revealed by videodermoscopy. In: Tosti A, editor. Dermoscopy of Hair and Scalp Disorders. 1st ed. London: Informa Healthcare; 2007. p. 1‑14. 2. Calonj E. Soft‑tissue tumors and tumour‑like conditions. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology. 8th ed. Malden: Blackwell; 2010. p. 56.25. 3. Harris MN, Desai R, Chuang TY, Hood AF, Mirowski GW. Lobular capillary hemangiomas: An epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol 2000;42:1012‑6. 4. Fortna RR, Junkins‑Hopkins JM. A case of lobular capillar y hemangioma (pyogenic granuloma), localized to the subcutaneous tissue, and a review of the literature. Am J Dermatopathol 2007;29:408‑11. 5. Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997;37:887‑919. 6. Demir Y, Demir S, Aktepe F. Cutaneous lobular capillary hemangioma induced by pregnancy. J Cutan Pathol 2004;31:77‑80. 7. Zaballos P, Carulla M, Ozdemir F, Zalaudek I, Bañuls J, Llambrich A, et al. Dermoscopy of pyogenic granuloma: A morphological study. Br J Dermatol 2010;163:1229‑37. How to cite this article: Ankad BS, Beergouder SL, Shaik MA. Pink nodule with a peculiar pattern on Trichoscopy. Int J Trichol 2013;5:161-2.
New features on the journal’s website Optimized content for mobile and hand-held devices HTML pages have been optimized of mobile and other hand-held devices (such as iPad, Kindle, iPod) for faster browsing speed. Click on [Mobile Full text] from Table of Contents page. This is simple HTML version for faster download on mobiles (if viewed on desktop, it will be automatically redirected to full HTML version) E-Pub for hand-held devices EPUB is an open e-book standard recommended by The International Digital Publishing Forum which is designed for reflowable content i.e. the text display can be optimized for a particular display device. Click on [EPub] from Table of Contents page. There are various e-Pub readers such as for Windows: Digital Editions, OS X: Calibre/Bookworm, iPhone/iPod Touch/iPad: Stanza, and Linux: Calibre/Bookworm. E-Book for desktop One can also see the entire issue as printed here in a ‘flip book’ version on desktops. Links are available from Current Issue as well as Archives pages. Click on View as eBook 162
International Journal of Trichology / Jul-Sep 2013 / Vol-5 / Issue-3
Copyright of International Journal of Trichology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
![[A pink nodule on the face].](/assets/img/hold.png)
