Intralesional sclerotherapy for angiokeratoma of Fordyce: A case report

Abstract

A 46-year-old male presented with a 6-year history of progressive, purplish-red, hyperkeratotic papules on the scrotum. These lesions bled during intercourse and routine activities, causing significant distress. Clinical examination and pathological evaluation confirmed the diagnosis of angiokeratoma of Fordyce. Due to patient preference and cost-effectiveness, sclerotherapy with 3% sodium tetradecyl sulfate was chosen. Following topical anesthesia, the lesions were injected with the sclerosing agent. After two sessions spaced 2 weeks apart, complete resolution of both the smaller and larger lesions was achieved. This case report expands the therapeutic options for angiokeratoma of Fordyce and highlights the successful utilization of 3% sodium tetradecyl sulfate sclerotherapy in achieving complete clearance with minimal invasiveness and cost.

Introduction

Angiokeratoma of Fordyce is a rare benign cutaneous vascular lesion, typically presenting as multiple, well-circumscribed, dome-shaped papules, primarily found on the scrotum or vulva.^1,2 These lesions are characterized by their purplish-red color and can range from 2 to 5 mm in diameter.^1,2 While angiokeratomas are generally asymptomatic, they can cause discomfort, pain, pruritus, and bleeding, leading patients to seek medical intervention for symptomatic relief or cosmetic concerns. ² Various treatment modalities have been employed for angiokeratomas, including electrocautery, cryotherapy, excision, laser therapy, and, more recently, sclerotherapy.^3–6 With only one published case report from 2010 showcasing its efficacy, sclerotherapy deserves reevaluation. ⁶ This case report research delves into the potential of 3% sodium tetradecyl sulfate (STS) as a cost-effective, patient-friendly, and machinery-free alternative to conventional modalities, paving the way for a potentially transformative approach to managing angiokeratomas.

Case presentation

A 46-year-old male presented with a chief complaint of purplish-red raised lesions on the scrotum persisting for 6 years. Initially small, the lesions gradually increased in size, affecting both sides of the scrotum. The patient reported discomfort and bleeding during sexual intercourse and routine activities. Upon examination, multiple hyperkeratotic, bluish-red papules (1 mm–3 mm) were observed and clinically diagnosed as angiokeratoma of Fordyce. Differential diagnoses including Kaposi sarcoma were considered and ruled out. No comorbidities were noted, and family history was negative. Lesions were also present in other body areas. Sclerotherapy was planned, preceded by routine biochemical investigations, including complete blood count, bleeding and clotting time, blood sugar, liver and kidney function tests, lipid profile, X-ray, and viral markers, all of which were normal. No immunohistochemistry was performed.

On the procedure day, topical anesthesia was applied under occlusion for 30 min using 3% STS (sodium-tetradecyl). Interlesional injections were administered with an insulin syringe, delivering 1 unit into each lesion, followed by compression. Mild pain during the procedure was effectively managed with analgesics.

After 2 weeks, smaller lesions and some larger lesions fully regressed (Figure 1). However, a few larger lesions persisted, necessitating an additional sclerotherapy session after another 2 weeks, resulting in complete regression. At the 1-month follow-up, no apparent side effects were observed, and all lesions had completely regressed.

Figure 1.

(a) and (b) Fordyce angiokeratoma (before treatment), (c) and (d) follow-up at 2 weeks—lesions have attained almost complete resolution.

Discussion

The progression of angiokeratomas of Fordyce is often gradual and, while typically asymptomatic, it can be distressing for some patients due to the potential for pain, itching, and bleeding, particularly during sexual activity, causing heightened anxiety. ³ Managing angiokeratoma of Fordyce poses challenges due to its multifocal nature, especially in individuals with dark skin who may exhibit increased skin thickness and hyperkeratosis. Traditional treatment modalities, such as excision, electrocoagulation, cryotherapy, and lasers, have limitations, especially in cases involving multiple lesions.^3–6 Excision may be restricted by the presence of multiple lesions or those with intricate patterns that are challenging to excise. Electrocoagulation and cryotherapy are limited by their potential to induce pigmentary changes and scarring.^3–5

Seo et al. ⁶ published a case report similar to the present case exploring the use of sclerosing agents for angiokeratoma treatment. The report highlights the efficacy of 3% STS, an FDA-approved sclerosing agent used for vascular conditions such as telangiectasia, reticular veins, and varicose veins. STS, available in 1% and 3% concentrations, induces endothelial damage through protein denaturation, leading to vessel wall occlusion and fibrosis. Compared to other sclerosing agents, STS presents fewer complications post-sclerotherapy, including pigmentation, anaphylaxis, and thrombus formation.

In our case, a single injection of STS resulted in significant improvement, characterized by flattening and necrosis of smaller lesions. Larger lesions required two additional injections administered in separate sessions for clearance. Minimal long-term side effects were observed, with mild pain and pigmentation being the primary concerns. Sclerotherapy emerges as a targeted approach for angiokeratoma treatment, offering the advantage of preserving surrounding skin compared to excision, cautery, or cryotherapy.

Conclusion

This rare case report highlights the gradual development and potential distressing symptoms associated with angiokeratoma of Fordyce. Traditional treatment options, including excision, electrocoagulation, cryotherapy, and lasers, face limitations, particularly when dealing with multiple lesions. In this case, the use of 3% STS as a sclerosing agent proved to be a promising intervention. Significant improvement was observed with STS injections in smaller lesions, and larger lesions showed clearance after two sessions. Sclerotherapy emerges as a targeted and valuable approach for treating angiokeratoma of Fordyce, offering minimal impact on the surrounding tissue. This underscores its potential as a preferred option in managing this dermatological condition.