Sir,

Angiokeratomas are asymptomatic, benign, cutaneous vascular tumors that may be difficult to differentiate clinically from other tumors. They present as papules with a scaly surface that sometimes bleed spontaneously. Treatment is often unnecessary [1]. However, the demand for radical treatment is for aesthetic and functional purposes. Several therapeutic modalities are available, including laser therapy.

A 39-year-old male, followed for hepatic cirrhosis complicated by portal hypertension under anticoagulant treatment and stage III varicocele, consulted for painless, non-pruritic, and spontaneously bleeding lesions on the scrotum that had been progressively evolving for four years. A dermatological examination revealed multiple erythemato-violaceous papules, and angiomatoses of 2–4 mm with a slightly scaly surface on the scrotum (Figs. 1a and 1b). Red and dark lagoons were noted on dermoscopy. The rest of the skin examination showed a varicose cord under the skin on the left testicle. A skin biopsy confirmed the diagnosis. Given the patient’s aesthetic and functional discomfort, treatment with a long-pulse Nd: YAG laser of 1064 nm and 200 J were recommended, with a satisfactory evolution after two sessions with a two-month interval. No recurrence was observed over a follow-up period of one year (Fig. 2).

	Figure 1: (a and b) Multiple erythemato-violaceous papules with a slightly scaly surface on the scrotum before Nd:YAG laser therapy.
	Figure 2: Appearance of the scrotum after two Nd:YAG laser sessions with the total disappearance of lesions.

Angiokeratomas are benign cutaneous vascular lesions characterized by dilated thin-walled blood vessels in the upper dermis, most often associated with an epidermal reaction such as acanthosis and/or hyperkeratosis [1]. These are well-limited millimeter-sized papules of variable size, livid red or bluish black in color, with a smooth, rarely rough, hyperkeratotic surface with red and dark lagoons on dermoscopy. It may result in diffuse scrotal erythema if the surface vessels are dilated [2]. Only 39% of men had symptoms associated with angiokeratoma, such as bleeding, enlargement, and less often an abrupt onset, pain, and pruritus. Generally, spontaneous or trauma-induced bleeding is rare [3]. However, therapeutic management is warranted when symptoms such as bleeding are present or for aesthetic purposes as in our patient’s case.

There are several therapeutic modalities, including excision, electrodesiccation, cryotherapy, or laser treatment, including 1064 nm, long pulse Nd: YAG, although there were no specific references for the success of this method [4]. Nevertheless, only several studies and case reports have been reported on angiokeratomas treated with different lasers such as long-pulse Nd: YAG laser [5], diode laser, 585 nm pulsed dye laser [6], combined Er: YAG, and 532 nm KTP (frequency-doubled Nd: YAG laser). These report good permanent cosmetic results with minimal adverse effects.

In a different case report, the authors suggested that angiokeratomas should be assessed individually based on the intensity of hyperkeratosis of each lesion before proposing the appropriate type of laser. Civas et al. [4] obtained excellent results without recurrence or adverse effects with the use of a long-pulse 1064 nm Nd: YAG laser alone, although this type of laser only targets hemoglobin, which was consistent with our results. Meanwhile, Bechara et al. reported atrophic scarring and hyperpigmentation as adverse effects [7] and recurrence after five years of repeated Nd: YAG laser use alone. However, this method remains the choice over surgery, which may be mutilating.

Consent

The examination of the patient was conducted according to the principles of the Declaration of Helsinki.

The authors certify that they have obtained all appropriate patient consent forms, in which the patients gave their consent for images and other clinical information to be included in the journal. The patients understand that their names and initials will not be published and due effort will be made to conceal their identity, but that anonymity cannot be guaranteed.

REFERENCES

1.Inakanti Y, Narsimha Rao TV. A tricky man issue:Angiokeratomas of scroti. Our Dermatol Online. 2015;6:179-82.

2.Miller C, James WD. Angiokeratoma of Fordyce as a cause of red scrotum. Cutis. 2002;691:50-1.

3.Cohen PR, Celano NJ. Penile angiokeratomas revisited:A comprehensive review. Dermatol Ther. 2020;104:551-67.

4.CivaşE, KoçE, Aksoy B, Aksoy HM. Report of two angiokeratoma of Fordyce cases treated with a 1064 nm long-pulsed Nd:YAG laser. Photodermatol Photoimmunol Photomed. 2009;253:166-8.

5.Del Pozo J, Fonseca E. Angiokeratoma circumscriptum naevi-forme:Successful treatment with carbon-dioxide laser vaporization. Dermatol Surg. 2005;31:232-6.

6.Lapidoth M, Ad-El D, David M, Azaria R. Treatment of angiokeratoma of Fordyce with pulsed dye laser. Dermatol Surg. 2006;32:1147-50.

7.Bechara FG, Jansen T, Wilmert M, Altmeyer P, Hoffmann K. Angiokeratoma Fordyce of the glans penis:Combined treatment with erbium:YAG and 532nm KTP (frequency doubled neodymium:YAG) laser. J Dermatol. 2004;31:943-5.