Dermoscopic features of cutaneous lymphangioma circumscriptum of the scrotum

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Dermoscopic features of cutaneous lymphangioma circumscriptum of the scrotum

Cutaneous lymphangioma circumscriptum (CLC) is a rare, non-cancerous skin condition caused by abnormal lymphatic vessel growth in the deep skin layers. While it’s the most common type of lymphangioma, it almost never affects the scrotum—making cases like the one we studied particularly interesting. Dermoscopy, a non-invasive tool that magnifies skin lesions, has greatly improved CLC diagnosis. But when CLC appears on the scrotum, its dermoscopic features might not match what doctors usually see. A team of dermatologists from Wuhan No.1 Hospital and Southern Medical University—including Jing Dong, Er-Yi Lin, Liang Zhang, and Liu-Qing Chen—investigated this in a 19-year-old patient with scrotal CLC, and our findings were published in the Chinese Medical Journal in 2020.

The Patient’s Story

A 19-year-old man came to our clinic with a 5-year history of painless, fluid-filled bumps on his scrotum. Sometimes the bumps burst, oozing out a thick, clear fluid (serous fluid), and leaving pale yellow crusts. He’d had surgery to remove the affected area a year earlier—without a biopsy—but the bumps came back months later. He had no history of sexually transmitted infections, radiation therapy, or serious infections like filariasis or tuberculosis.

When we examined him, his entire scrotum was covered in small white vesicles (1–3 mm wide). The skin underneath was thickened and swollen. An ultrasound showed a fluid buildup around his left testicle (hydrocele) and swelling in the scrotal wall.

Dermoscopy—using a special magnifying device—revealed dense, white or yellowish “lacunae” (small cavities) surrounded by pale yellow or yellow-white structures. At the bottom of these lacunae were red-violet spots. Unlike typical CLC lesions (which are often transparent or translucent), these looked like a white or yellowish mulberry.

We confirmed the diagnosis with a skin biopsy. Under the microscope, the epidermis was raised and thickened (papillated hyperkeratosis). There were multiple dilated lymphatic vessels lined with thin endothelial cells—filled with lymph fluid, red blood cells, and a sticky, eosinophilic (pink-staining) substance. The collagen fibers around these vessels were overgrown (hyperplasia). Immunohistochemistry tests—using markers to identify cell types—showed the vessels were lymphatic (D2-40+ and CD31+) but not blood vessels (CD34-). The patient gave written consent for his images and clinical details to be published, with efforts to protect his privacy (though complete anonymity can’t be guaranteed).

What We Know About CLC

CLC usually starts at birth or in childhood, though it can develop later (acquired CLC) from damage to deep lymph vessels—like from radiation or infections. It most often appears on the upper body (neck, armpits, trunk) but rarely affects the genitals.

Typical CLC lesions are clusters of transparent or hazy vesicles filled with clear lymph fluid (sometimes mixed with blood). On the scrotum, these can be mistaken for other conditions: molluscum contagiosum (small, shiny bumps), condyloma acuminata (genital warts), or idiopathic calcinosis cutis (hard calcium deposits). A biopsy is usually needed to confirm, but dermoscopy helps narrow it down.

For most CLC cases, dermoscopy shows two main patterns:

  1. Yellow lacunae (cavities) surrounded by pale “septa” (walls) with no blood.
  2. Yellow or pink lacunae mixed with dark red or blue ones (from blood).

Some cases also have a “hypopyon-like feature”—a layered look similar to white blood cells settling in the eye. These patterns match what’s seen under the microscope: dilated lymph vessels with or without blood.

Why This Scrotal Case Was Unique

Our patient’s scrotal CLC looked different. Instead of transparent vesicles, the lesions were opaque (white/yellowish) and looked like a mulberry. We didn’t see the hypopyon-like features or sharp blood vessels common in other CLC cases.

Why? The histopathology gave us a clue: the lymph vessels were surrounded by overgrown collagen fibers (fibroplasia). This collagen hyperplasia likely made the vesicles less transparent—explaining the mulberry-like appearance. The pale yellow structures around the lacunae might be from eosinophilic keratin (a protein in skin cells) seen in the biopsy.

Key Takeaways

Dermoscopy is a powerful tool for diagnosing CLC, with key features like lacunae, blood vessels, and hypopyon-like patterns. But our scrotal case shows that CLC can look different depending on where it grows. The mulberry-like appearance and lack of transparency were linked to collagen overgrowth around the lymph vessels—something unique to this site. For doctors, this means being aware that scrotal CLC might not fit the “usual” dermoscopy rules—and using biopsy to confirm when in doubt.

This work was supported by a grant from the Wuhan Science and Technology Foundation (No. 2019010701011418). The authors reported no conflicts of interest.

References

  1. Patel GA, Schwartz RA. Cutaneous lymphangioma circumscriptum: frog spawn on the skin. Int J Dermatol 2009;48:1290–1295. doi: doi.org/10.1111/j.1365-4632.2009.04226.x
  2. Arpaia N, Cassano N, Vena GA. Dermoscopic features of cutaneous lymphangioma circumscriptum. Dermatol Surg 2006;32:852–854. doi: doi.org/10.1111/j.1524-4725.2006.32174.x
  3. Amini S, Kim NH, Zell DS, Oliviero MC, Rabinovitz HS. Dermoscopic-histopathologic correlation of cutaneous lymphangioma circumscriptum. Arch Dermatol 2008;144:1671–1672. doi: doi.org/10.1001/archderm.144.12.1671
  4. Gencoglan G, Inanir I, Ermertcan AT. Hypopyon-like features: new dermoscopic criteria in the differential diagnosis of cutaneous lymphangioma circumscriptum and haemangiomas. J Eur Acad Dermatol Venereol 2012;26:1023–1025. doi: doi.org/10.1111/j.1468-3083.2011.04136.x
  5. Zaballos P, Del Pozo LJ, Argenziano G, Karaarslan IK, Landi C, Vera A, et al. Dermoscopy of lymphangioma circumscriptum: a morphological study of 45 cases. Australas J Dermatol 2017;59:e189–e193. doi: doi.org/10.1111/ajd.12668

Our study’s full details are available at doi.org/10.1097/CM9.0000000000000957

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