Cutaneous Angiokeratoma Treated With Surgical Excision and a 595-nm Pulsed Dye Laser

Angiokeratomas are vascular neoplasms with hyperkeratotic red to black papules and plaques, which may present as solitary or multiple lesions with variations in color, shape, and location.

Angiokeratomas are clinically classified as follows: widespread forms (angiokeratoma corporis diffusum) and localized forms [solitary angiokeratoma, angiokeratoma of Mibelli, angiokeratoma scroti (angiokeratoma of Fordyce), and angiokeratoma circumscriptum naeviforme].¹ The color tone, size, ridge, and localization of lesions differ depending on the type and case. Angiokeratomas, though often asymptomatic, may present with symptoms such as bleeding, itching, and a cosmetic psychological burden.¹ Treatment should target both cosmetic and symptom improvement. Treatments such as surgical excision, electrical stimulation, ablation, cryotherapy, and laser treatment have been reported, but angiokeratomas can be difficult to treat due to the necessity of appropriate treatment depending on the clinical condition of the lesion, especially in cases of extensive lesions and protuberance. This report describes 2 cases of angiokeratoma treated with surgical excision and a 595-nm pulsed dye laser (PDL).

Case 1

A 7-year-old female presented with a painful mass in the right popliteal fossa from 3 years of age. The mass density gradually increased, and bleeding from the lesion started at 6 years of age. She was referred for treatment (Figure 1a). The patient’s medical and family history were unremarkable. She presented with a purple to black protruding mass, small papules, and red plaques in the right popliteal area to the proximal lower leg. Surgical excision of the 2 lesions with continuous bleeding was performed. Histopathological examination revealed hyperkeratosis and cavernously enlarged blood vessels (Figure 1b). Subsequently, abrasion of the wart-like small papules was performed with a scalpel. Small red dots and macules were treated with a 595-nm PDL (Vbeam Perfecta; Candela Corporation). The parameters were as follows: 10-mm spot size; pulse durations of 1.5, 3, and 10 ms; energy fluence of 7.5 to 8.25 J/cm²; and use of a dynamic cooling device (DCD). Irradiation was performed 3 times at intervals of 3 to 10 months. 

Case 2

A 15-year-old female had a purple-black nodule on the left thigh since she was 12 years of age. The number of nodules slowly increased, and small red to purple dots gradually began to spread in the lower extremities and forearms (Figure 2a). She was referred for treatment. The patient’s medical and family history were unremarkable. She presented with a purple protruding mass in her left thigh and small papules in both lower extremities and forearms. Surgical excision of the 2 raised lesions and a subcutaneous mass was performed. Histopathologically, the resected specimen showed dilation of veins and hypervascularization just below the epidermis (Figure 2b). Small red dots and macules were treated with a 595-nm PDL (Vbeam Perfecta). The parameters were as follows: 10-mm spot size, pulse duration of 10 ms, energy fluence of 8.5 to 9 J/cm², and DCD 40/20. Irradiation was performed every 3 to 4 months. 

Case 1

Pigmentation occurred, but cosmetic improvement was observed (Figure 1c).

Case 2

Remarkable cosmetic improvement was observed (Figure 2c).

PDL is a laser designed using the concept of selective photothermolysis for the treatment of vascular lesions.² The light from the PDL is selectively absorbed into hemoglobin in a vessel. Hemoglobin absorbs the light energy of the laser and replaces it with heat, causing the inner wall of the blood vessel to be thermally destroyed; as a result, the vascular lesions are treated.²

The effectiveness of PDL therapy for angiokeratoma has been reported. In PDL treatment for angiokeratoma, several previous studies reported the following settings: fluence of 6.5 to 15 J/cm², spot size of 5 to 10 mm, pulse duration of 0.45 to 500 ms, and time interval between irradiation ranged from 3 to 12 weeks.¹ Su et al³ reported treatment with a 595-nm PDL in patients with angiokeratoma of Mibelli. The parameters were as follows: 7-mm spot size, pulse duration of 10 ms, energy fluence of 12 to 13.5 J/cm², and irradiation performed 1 to 4 times (every 4-6 weeks). It was reported that remarkable improvement was observed in 80% of cases, and complete remission was observed in 30%. Baumgartner et al⁴ reported the effectiveness of laser treatment on angiokeratomas of Fordyce with 595-nm PDL using the following parameters: for a 3-mm spot size, pulse durations of 0.45, 1.5, and 10 ms and energy fluence of 11 to 13.5 to 21 J/cm²; for a 5-mm spot size, pulse duration of 1.5 ms and energy fluence of 5.25 to 8 J/cm²; and for a 7-mm spot size, pulse duration of 10 ms and energy fluence of 9.5 to 15 J/cm². The number of treatments was 1 to 7 (every 1-3 months), and it was reported that the effect was remarkable in all patients. 

However, treatment with PDL is also limited. Previous literature reported that the penetration of PDL is up to approximately 1.25 to 2 mm,^5-7 depending on the beam diameter. There is a limit to the depth that the laser beam can reach, and it is thought that the effect is poor in cases with strong ridges, those with severe hyperkeratosis, and those with subcutaneous lesions. 

On the other hand, surgical excision, cryotherapy, and cautery may carry a risk of scarring and atrophy.¹

Not all angiokeratoma lesions may be in a uniform state; therefore, it is necessary to treat each lesion accordingly. In the present cases, surgical resection was performed for lesions with strong elevation and subcutaneous masses. In addition, abrasion was performed for small wart lesions in case 1. Treatment with PDL was performed on pigmented spots with few ridges.

Affiliations: Yodogawa Christian Hospital, Osaka, Japan

Correspondence: Misato Ueda, MD; sakuramochi0v0@yahoo.co.jp 

Ethics: Patients provided informed consent.

Disclosures: The authors disclose no financial or proprietary interest in the subject matter of this article.