Photo Rounds

Vesicles on the thigh

A 19-year-old woman presented to Dermatology with a 3-year history of vesicles on her thigh. Close inspection revealed layers of fluid in small vesicles resembling the glass chambers in a Galilean thermometer. On physical exam, there were multiple 3- to 10-mm vesicles grouped together in a 10 × 10-cm area on the thigh. The patient denied any itching or pain but noted that the vesicles would occasionally bleed or leak straw-colored fluid with shaving.

What is your diagnosis?



Vesicles on the thigh

On very close inspection, the physician noted translucent chambers within each vesicle, and within each chamber there was a horizontal line (parallel to the floor) separating serum-colored fluid from dark blood. This unique appearance prompted the physician to diagnose lymphangioma circumscriptum in this patient.

Lymphangioma circumscriptum is a rare type of microcytic lymphatic malformation most commonly found on the shoulders, limbs, axilla, and tongue that may enlarge during puberty. The clustered vesicles are firm. Vesicles can be red, brown, or straw colored in appearance and are focal to widespread; rarely, they may bleed or become infected. Their appearance has been compared to frog spawn.

Lymphangioma circumscriptum is benign and requires no treatment. Any suspected infection could be treated with antibiotics. If removal is desired for cosmesis or functional treatment, areas may be treated with dermabrasion, sclerotherapy, laser ablation, or excision if feasible. Lymphangioma circumscriptum tends to recur in time and appropriate anticipatory guidance is key.

This patient was treated with sclerotherapy using hypertonic saline that was injected monthly for 3 months. The physician injected a 30-g needle into the broadest ectatic chambers after each area was anesthetized with lidocaine. The patient tolerated the injections well, and the treated areas resolved as slightly hypopigmented macules. No recurrence was noted at posttreatment follow-up 1 year later.

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

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