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Case Reports

Abstract

Infantile hemangiomas (IH) are the most common vascular tumors in pediatric patients. Infantile hemangiomas with minimal or arrested growth (IH-MAG) have a proliferative component of less than 25% and can be misdiagnosed as other vascular malformations. While GLUT-1 staining is established in IH, the histologic appearance of IH-MAG and ulcerated IH are not well characterized. A 5-month-old female presented with an asymptomatic vascular patch on the right lower extremity and was diagnosed with a capillary malformation. At 8-months-of-age, the lesion developed black eschars, concerning for a thromboocclusive process. Punch biopsies showed necrosis of the epidermis and superficial dermis overlying superficial dermal vessels with intravascular fibrinous thrombi. The histologic picture was suggestive of a necrotizing vasculitis, but this was incongruent with the clinical history. Special stains were obtained and GLUT-1 was positive, confirming a diagnosis of IH-MAG with focal ulceration. The patient was started on timolol drops and then transitioned to oral propranolol 1.5 mg/kg/day. At follow up, the ulcerations had healed and the IH-MAG was fading. This case highlights the ability of IH-MAG to masquerade as other vascular anomalies, and offers rare insight into the clinicopathologic correlation of ulcerated infantile hemangiomas. While factors underlying the causation of ulceration have been explored, the histologic findings of ulcerated IH are not well characterized in the current medical literature. The histologic findings in this case may highlight a potential thromboocclusive etiology in ulcerating IH, and may illuminate why ulceration of IH often presents as crusting or necrotic eschars, rather than raw wound.