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Net Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_762_2023

Dermoscopic features of telangiectasia macularis multiplex acquisita

Hospital for Skin Disease and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
Corresponding author: Dr. Xiaopo Wang, Hospital for Skin Disease and Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China. 13770757675@163.com
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How to cite this article: Wang X. Dermoscopic features of telangiectasia macularis multiplex acquisita. Indian J Dermatol Venereol Leprol. doi: 10.25259/IJDVL_762_2023

Abstract

Telangiectasia macularis multiplex acquisita is a rarely described entity, characterized by multiple asymptomatic erythematous and/or brownish macules with telangiectasias, preferably on bilateral upper arms and trunk. We reported a 56-year-old Chinese man with telangiectasia macularis multiplex acquisita. Dermoscopic examination demonstrated an erythematous-brownish background with a striking angioid streak pattern (a central arteriole with superficial radiating small vessels attributed to spider-like eruptions) and linear-irregular branching vessels. We suggest dermoscopic features can be used to improve the accuracy of clinical diagnosis and avoid unnecessary skin biopsies.

Dear Editor,

Telangiectasia macularis multiplex acquisita (TMMA) is a rare condition that is characterised by numerous asymptomatic erythematous and/or brownish macules with telangiectasia, usually distributed on the upper arms and trunk.1 Several underlying diseases have been reported associated with TMMA, especially chronic liver disease.2 No previous reports could be found on using dermoscopy to evaluate TMMA.

A Chinese man aged 56 years presented with a series of asymptomatic, erythematous to brown skin eruptions on his upper arms and trunk which were appearing for the past 3 years. He had a history of hepatitis B for 10 years. Further more, a record of smoking and drinking for a duration exceeding 20 years was obtained. His dermatological examination revealed numerous well-demarcated erythematous to brownish macules with telangiectasia involving his back, bilateral upper limbs, and chest [Figures 1a and 1b]. Moreover, several spider-like eruptions were also found. The examination by dermoscopy demonstrated an erythematous-brownish background with a striking angioid streak pattern (a central arteriole with superficial radiating small vessels attributed to spider-like eruptions) and linear-irregular branching vessels [Figures 2a and 2b]. A skin biopsy showed that the basal layer of the epidermis had obvious hyperpigmentation and lymphohistiocytic infiltration was sparse around the dilated vessels in the upper dermis [Figure 3a]. No mast cells were observed by Giemsa staining [Figure 3b]. The routine blood investigations, including liver and kidney function tests were unremarkable. Hepatitis B s-antigen, E antibody or Anti-e, and Anti-c were positive. These findings were consistent with the diagnosis of TMMA.

Figure 1a:
Multiple well-demarcated erythematous to brownish macules with telangiectasia on the chest.
Figure 1b:
Multiple well-demarcated erythematous to brownish macules with telangiectasia on bilateral upper limbs.
Figure 2a:
Dermoscopy demonstrating erythematous-brownish background with prominent angioid steak pattern or linear-irregular branching vessels (polarizing, origninal magnification ×10).
Figure 2b:
Dermoscopy demonstrating erythematous-brownish background with prominent angioid steak pattern or linear-irregular branching vessels (polarizing, origninal magnification ×10).
Figure 3a:
Histopathology revealed marked hyperpigmentation in the basal layer of the epidermis, and mild lymphohistiocytic infiltration (black arrows) around the dilated vessels in the upper dermis (Haematoxylin & Eosin, 100x).
Figure 3b:
No mast cells were observed (Giemsa stain, 100x).

The aetiology of the TMMA is unknown. Vessel defects resulting from either a birth defect or ageing may play a role in pathogenesis. In addition, it has been inferred that abnormal oestrogen metabolism in liver disease especially as viral markers are positive may cause vascular changes.2

Some authors suggested the entity ‘acquired bilateral telangiectatic macules (ABTM)’ for people with numerous telangiectatic pigmented macules mostly on their upper arms which demonstrated similar clinical features and histopathological characteristics as TMMA.3 Furthermore, a disease called acquired bilateral telangiectasia macularis eruptive perstans (TMEP) is a common disorder among middle-aged or older Asian men. Some proposals acquired bilateral TMEP and ABTM should be regarded as a continuum of disorder.4 Hence, we think that the identical disease entity was addressed in all three instances owing to the remarkably similar clinical and pathological outcomes.

The differential diagnosis should include some diseases with similar telangiectasia, such as TMEP and generalised essential telangiectasia (GET) [Table 1]. TMEP is often confused with TMMA due to its similar clinical presentation. The dermoscopy showed that TMEP has a typical reticular vascular pattern of linear and branching vessels.5 However, the vessels in TMMA are mostly linear and irregular with few showing branching. In addition, the histological features of TMEP indicate that there are infiltrations of mast cells, primarily situated around dilated capillaries in the upper dermis which are accentuated by Giemsa staining. The majority of GET cases are middle-aged females, characterised by telangiectasia on the lower legs, gradually progressing to the upper legs, abdomen, and arms. The presence of fine arborizing vascular dilations on dermoscopy helps to differentiate GET from TMMA.6

Table 1: Distinctive features of TMMA, TMEP, and GET
TMMA TMEP GET
Age of onset Adult Adult Adult
Site of predilection Bilateral upper arms and trunk Trunk and limbs Lower legs
Association Chronic liver diseases - -
Dermoscopic patterns Predominantly linear-irregular, with few showing branching Reticular vascular pattern of linear and branching vessels Fine arborizing vascular dilation
Histopathology Mild inflammation with or without telangiectasia in the upper dermis Mast cells in the upper dermis and clustered around dilated capillaries Dilated blood vessels in upper dermis

TMMA: telangiectasia macularis multiplex acquisita, TMEP: telangiectasia macularis eruptiva perstans, GET: generalised essential telangiectasia

Due to its benign nature and asymptomatic course, patients usually do not require treatment. For aesthetics, a pulsed dye laser could be chosen, considering its effect on telangiectasia. In conclusion, TMMA is not uncommon and probably unreported among Asian men. Dermoscopic features can be used to make the clinical diagnosis more accurate and avoid unnecessary skin biopsies.

Declaration of patient consent

The author certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The author confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

References

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  3. , , , , , . Acquired bilateral telangiectatic macules: A distinct clinical entity. JAMA Dermatol. 2014;150:974-7.
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  4. , , , , , . Acquired bilateral telangiectasia macularis eruptive perstans: A unique clinical feature of photodamaging rather than a subtype of cutaneous mastocytosis. J Dermatol. 2017;44:1276-80.
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