tufted angioma is a rare vascular neoplasm clinically characterized by slowly progressive pink to red macules or plaques on the neck , trunk , or shoulders of children or young adults .
these tumors follow a benign course of angiomatous proliferation , without any evidence of malignancy .
we report herein a case of multifocal tufted angiomas with annular morphology in a child for the rarity of the condition .
an 8-year - old boy was referred to us for the evaluation of multiple reddish elevations on the back , which were first noticed 4 years before presentation .
starting as two small reddish asymptomatic patches , the lesions gradually became elevated and fresh lesions appeared in the vicinity of the older ones .
the lesions have remained stable for the preceding several months . increased sweating over the patches was noted by the parents .
family history and past medical history was unremarkable . on examination , two brightly erythematous annular plaques of about 6 cm and 3 cm diameter
in addition , several erythematous papules and plaques of varying sizes were seen around the lesions as well as on the right side of the back .
routine laboratory tests , blood coagulation profile , and serum biochemistry panel were within normal limits .
two annular erythematous plaques and several papules and plaques of varying sizes on the back we considered the differential diagnoses of tufted angioma , sudoriferous angioma ( eccrine angiomatous hamartoma ) , and capillary hemangioma .
crescent - shaped cleft like spaces were seen around the lobules [ figures 2 and 3 ] .
based on the clinical findings and characteristic histology , a diagnosis of tufted angioma was made .
after discussion about the possible modalities of treatment and the chance of spontaneous regression , the parents preferred regular follow - up without any active intervention and the child was kept under observation .
histopathology showing well - circumscribed poorly - canalized capillary lobules in the dermis with crescent - shaped spaces around them .
h and e , 100 showing well - defined capillary tufts surrounded by crescent - shaped clefts .
ta was described for the first time by wilson jones in 1976 as an acquired vascular proliferation of peculiar histological characteristics and reports of additional cases had helped better characterization of this clinicopathologic entity .
it commonly presents in infancy or early childhood , though adult - onset cases have been reported also .
ta usually presents as a macule , papule or plaque over the upper trunk , neck and proximal part of the limbs ; involvement of other locations like face , oral mucosa and lip is also known .
ta is a sporadic disease with more than half of the cases occurring during the first 5 years of life .
hyperhidrosis , as in our case , and hypertrichosis can also occur over the lesion .
eccrine sweat gland elements however were not seen to be increased in the histopathology of our patient .
ta should be differentiated from kaposiform hemangioendothelioma , juvenile capillary , or strawberry angioma , haemangiopericytoma , glomeruloid haemangioma , or pyogenic granuloma .
ta can however be diagnosed by the distinctive histopathological pattern characterized by the vascular tufts of densely packed capillaries , randomly scattered throughout the dermis in a so called  cannonball  configuration .
there are crescentic spaces surrounding the vascular tufts and lymphatic - like spaces within the tumor stroma .
immunohistochemical stains show strong positivity for ulex uropaeus i lectin and en4 and unlike infantile hemangioma , negative staining for glut 1 .
ta , like kaposiform hemangioendothelioma , may be associated with the kasabach - merritt syndrome ( kms ) .
physicians should look for the appearance of petechiae or ecchymotic patches and if they occur , a complete hemogram ( including a platelet count ) , prothrombin time and/or activated partial thromboplastin time and full screening for disseminated intravascular coagulation should be ordered .
common association with kms , morphologic similarity , association in the same patient , and common expression of lymphatic markers had led to the suggestion that ta may be a minor form of kaposiform hemangioendothelioma or part of a spectrum of the same condition .
ta usually pursue a persistent course , but spontaneous regression may occur in a proportion of cases .
different modalities of treatment including complete surgical excision , cryosurgery , and radiotherapy had been tried for ta .
pulsed dye laser has also been reported as an effective option for treatment of ta .
embolization and vincristine are found to be effective in patients having kms . in conclusion , we have reported a rare case of multiple tufted angiomas with annular morphology in a child .
the possibility of this tumor should be kept in mind while dealing with patients having lesions of similar morphology .
we described a boy who had multifocal lesions with large annular plaques as well as papules and nodules .
 tufted angioma ( ta ) is a localized benign hamartomatous vascular proliferation usually presenting in the childhood as an erythematous plaque . 
 we report here a rare case of multifocal ta in an 8-year - old boy who presented which two large annular lesions as well as multiple papules and nodules on the back for the duration of 4 years . 
 histology showed typical well circumscribed poorly canalized vascular lobules with  
 cannon ball configuration . 
Introduction
Case Report
Discussion