Cherry hemangiomas are common benign cutaneous vascular proliferations. They are also known as cherry angiomas, adult hemangiomas, or senile angiomas as their number tends to increase with age.[rx] They were named Campbell De Morgan spots, after the name of a surgeon who worked at Middlesex hospital from 1842 to 1875.[rx] According to the current classification by the International Society for Vascular Anomalies (ISSVA) for benign vascular tumors, cherry hemangiomas are not included although they have distinct clinical and histopathological features and are highly prevalent in adults.[rx]
Cherry angiomas, also known as senile angiomas, are common vascular benign tumors. They generally develop after the third decade of life [rx]. Cherry angiomas, also known as Campbell de Morgan spots or senile angiomas,[rx] are cherry red[rx] papules on the skin. They are a harmless benign tumor, containing an abnormal proliferation of blood vessels, and have no relationship to cancer. They are the most common kind of angioma, and increase with age, occurring in nearly all adults over 30 years.
According to light and electron microscopic study of telangiectasia, cherry hemangiomas are a type of papular telangiectasia. These true capillary hemangiomas consist of newly formed capillaries that have narrow lumens and prominent endothelial cells that are arranged in a lobular pattern in the papillary dermis.[rx] Cherry hemangiomas generally appear as multiple spots, 1 to 5 mm in size, bright red, and dome-shaped papules mostly on the trunk or upper limbs and rarely on hands, feet, and face.[rx]
Causes of Cherry Hemangiomas
There is no well-known cause of cherry angiomas. Some of the associations and possible etiologies of these lesions are as follows.
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Aging – Since these lesions are seen mostly in old age, the aging process can be a cause of their development.[rx]
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Genetic mutation – Some studies have seen somatic missense mutations in GNAQ (Q209H, Q209R, R183G) and GNA11 (Q209H) genes in these lesions.[rx]
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Pregnancy
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A side effect of topical nitrogen mustard used for the treatment of vitiligo[rx]
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A side effect of cyclosporine[rx]
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Chronic graft-host disease[rx]
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Lymphoproliferative diseases and multicentric Castleman disease (MCD) – The possible mechanism is hypersecretion of vascular endothelial growth factor in response to elevated interleukin 6 levels. Therefore, it is suggested that if the patient presents with sudden multiple cherry angiomas along with systemic symptoms and lymphadenopathy, the patient should be evaluated for multicentric Castleman disease (MCD) and other lymphoproliferative disorders.[rx]
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A side effect of ramucirumab – The underlying mechanism for this is ramucirumab-induced somatic activating VEGFR2 mutation.[rx]
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Human herpesvirus-8 (HHV8) – It is frequently found in eruptive cherry hemangiomas (52.9%)[rx]
- Cherry angioma may occur through two different mechanisms – angiogenesis (the formation of new blood vessels from pre-existing vessels), and vasculogenesis (the formation of totally new vessels, which usually occurs during embryonic and fetal development).[rx]
- Chemicals and compounds – that have been seen to cause cherry angiomas are mustard gas,[rx][rx][rx][rx] 2-butoxyethanol, bromides, and cyclosporine.[rx] A significant increase in the density of mast cells has been seen in cherry hemangiomas compared with normal skin.[rx]
One study published in 2010 found that a regulatory nucleic acid suppresses protein growth factors that cause vascular growth. This regulatory nucleic acid was lower in tissue samples of hemangiomas, and the growth factors were elevated, which suggests that the elevated growth factors may cause hemangiomas.[rx] The study found that the level of microRNA 424 is significantly reduced in senile hemangiomas compared to normal skin resulting in increased protein expression of MEK1 and cyclin E1. By inhibiting mir-424 in normal endothelial cells they could observe the same increased protein expression of MEK1 and cyclin E1 which, important for the development of senile hemangioma, induced cell proliferation of the endothelial cells. They also found that targeting MEK1 and cyclin E1 with small interfering RNA decreased the number of endothelial cells.
A study published in 2019 identified that somatic mutations in GNAQ and GNA11 genes[rx] are present in many cherry angiomas. These specific missense mutations found in hemangiomas are also associated with port-wine stains and uveal melanoma.
Symptoms of Cherry Hemangiomas
Cherry angiomas are made up of clusters of capillaries at the surface of the skin,[rx] forming a small round dome (“papule”),[rx] which may be flat-topped. They range in color from bright red to purple. When they first develop, they may be only a tenth of a millimeter in diameter and almost flat, appearing as small red dots. However, they then usually grow to about one or two millimeters across, and sometimes to a centimeter or more in diameter. As they grow larger, they tend to expand in thickness and may take on the raised and rounded shape of a dome. Multiple adjoining angiomas form a polypoid angioma.[rx] Because the blood vessels comprising an angioma are so close to the skin’s surface, cherry angiomas may bleed profusely if they are injured.[rx]
One study found that the majority of capillaries in cherry hemangiomas are fenestrated and stain for carbonic anhydrase activity.[rx]
Diagnosis of Cherry Hemangiomas
Histologic examination of these lesions shows that they are located immediately under the epidermis in the papillary dermis and have a distinct structure from surrounding tissues.[rx] These are true capillary hemangiomas that consist of newly formed capillaries that have narrow lumens and are lined by prominent endothelial cells that are arranged in a lobular pattern.[rx] The capillaries forming cherry hemangioma show perivascular hyalinized sheaths. On immunohistochemical staining, perivascular hyalinized sheath and intercapillary connective tissue of the hemangiomas show marked staining for type VI collagen.[rx]
History and Physical
Cherry hemangiomas are dome-shaped, bright, ruby-colored papules with a pale halo. They are small, well-demarcated, and often separated by septa. They are usually 1 to 5 millimeters in diameter. They occur most often as multiple lesions, usually found on the trunk or proximal extremities. They are rarely seen on the face, hands, and feet. When found in the form of multiple adjoining angiomas, they are said to form a polypoid angioma. These lesions most often blanch with applied pressure, but some are fibrotic and may not blanch completely.[rx]
These lesions are the most common type of acquired vascular proliferation of the skin. They are diagnosed clinically by appearance. These lesions have no malignant potential. Although they have no malignant potential, they may be confused with amelanotic melanoma, which, in contrast, is more friable.[rx]
Evaluation
Cherry hemangiomas are diagnosed clinically by appearance. Optical coherence tomography, which is a low energy light-based imaging device, can be used to evaluate cherry hemangiomas before treating them with laser therapy. This imaging study determines the extent and depth of these lesions, which is useful in predicting the response of these lesions to laser therapy.[rx] If there is a concern for malignancy, the lesion should be excised and sent for histopathologic examination.[rx]
Although cherry hemangiomas are diagnosed clinically by appearance, their histopathologic findings are essentially the same as true capillary hemangiomas.[rx] These histopathologic findings include a thinned epidermis and many newly developed, polypoid, neovascularized capillaries. These capillaries have thin narrow lumens along with prominent endothelial cells. The endothelial cells are most often arranged in a lobular fashion in the papillary dermis.[rx] The newly formed capillaries are found early, while these capillaries dilate later. Therefore, late-stage tumors often tend to have increased dilated vessels.[rx] The proliferative activation of endothelial cells may therefore be specific to the early stage and may disappear in the later stage.[rx]
In addition to these findings, collagen fibers between blood vessels appear to be homogenous and show edematous changes. The epidermis may be atrophic, as characterized by loss of rete ridges. The epidermal collarette is similar in appearance to pyogenic granuloma. In addition, immunohistochemical staining demonstrates no abnormality in the expression or distribution of alpha-smooth-muscle actin and type IV collagen on the capillaries of cherry hemangiomas that have undergone proliferation. The dilated and congested vessels demonstrated through immunohistochemical staining may be responsible for the bright ruby-red appearance of cherry hemangiomas.[rx] The atrophic epidermis and proximity to the epidermis also demonstrated through immunohistochemical staining, may be responsible for the ease of bleeding of these lesions secondary to trauma.
Treatment of Cherry Hemangiomas
These lesions are most often asymptomatic but may bleed with trauma.[rx]
- Patients may want to remove a cherry hemangioma, most often for either cosmetic reasons or for the prevention of bleeding following trauma.[rx] Treatment for smaller lesions includes local anesthesia with 1% lidocaine, followed by electrocauterization. Larger lesions are often treated with shave excision, with electrocauterization of the base. In addition, cryotherapy may be employed. Superficial lesions may also be treated with CO2 laser therapy.[rx]
- Although traditionally cryosurgery, electrosurgery, or curettage have been employed in the treatment of cherry hemangioma, more recently, pulsed dye laser or intense pulsed light has been used with success. Krypton and 532 nm diode lasers work very well in eradicating these lesions.[rx] Patients should be advised that the removal of these lesions may cause scarring.[rx]
Electrocauterization
- This surgical method of treatment involves burning the angioma by using an electric current delivered by a tiny probe. For this procedure, you’ll also have a grounding pad placed somewhere on your body to ground the rest of your body from a surge of electricity.
Cryosurgery
- Cryosurgery involves freezing the angioma with liquid nitrogen. The extreme cold will destroy it. This method is known for being a quick and relatively easy procedure.
- You often only need one treatment session for cryosurgery to work, and the liquid nitrogen is usually sprayed for only about 10 seconds. The wound doesn’t require much care afterward.
Laser surgery
- This type of surgery involves using a pulsed dye laser (PDL) to get rid of the cherry angioma. The PDL is a concentrated yellow laser that gives off enough heat to destroy the lesion. This method is quick and is done as an outpatient procedure, which means you won’t have to stay in the hospital overnight.
- Depending on how many angiomas you have, you may need between one and three treatment sessions. This surgery can cause slight bruising, which can last up to 10 days.
Shave excision
- This procedure involves removing the angioma from the top portion of skin. Shave excision is an alternative to invasive surgery that would involve cutting out the lesion or growth and using stitches, or sutures, to close the wound.
- If you do have angiomas removed with any of these methods, scarring is uncommon but always possible.
Electrodesiccation
- Electrodesiccation is a method also known as electrocautery that involves burning off skin growths. Dermatologists commonly use this for benign tumors, serious skin cancers, and pre-cancers.
- First, the doctor will likely inject a local anesthetic. Then, they will touch the abnormal tissue with an electric needle to destroy the blood vessels and scrape off the angioma.
- The doctor then dresses the wound, and it remains that way until the wound heals.
As with excision, this method can cause some discomfort after the procedure. Electrodesiccation usually leaves a small, white scar.
References
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