Mimickers and differential diagnosis

Several other lesions can appear red, purple, or vascular under the dermatoscope. Knowing what can mimic a cherry angioma — and what distinguishes them — is essential for safe practice.

Angiokeratoma

An angiokeratoma is a benign vascular lesion with an overlying layer of thickened skin (keratin). Under the dermatoscope, angiokeratomas show dark red to black lacunae — similar to a cherry angioma — but with a characteristic whitish or grey veil over part or all of the surface. This veil corresponds to the keratotic crust.

Angiokeratomas are benign and do not require referral. The distinction from cherry angioma is largely academic, but recognising the veil-over-lacunae pattern prevents you from being alarmed by the darker colour.

Pyogenic granuloma

A pyogenic granuloma is a rapidly growing vascular nodule that bleeds easily. Under dermoscopy, it shows a reddish homogeneous area, often with a collarette of scale at the base and a whitish rail-like pattern. Unlike cherry angiomas, pyogenic granulomas grow quickly (over days to weeks), bleed with minimal trauma, and often have an irregular or eroded surface.

The key differentiator is the clinical history: rapid growth and easy bleeding are not features of cherry angioma.

Amelanotic or nodular melanoma

This is the mimicker that matters most. Amelanotic melanoma can present as a pink or red nodule that superficially resembles a vascular lesion. Under dermoscopy, it may show milky-red areas, irregular dotted or linear vessels, and sometimes remnant pigmentation at the periphery.

Kaposi sarcoma

In immunosuppressed patients, Kaposi sarcoma can present as purple-red lesions that may superficially resemble angiomas. Dermoscopy shows a characteristic multicoloured pattern — rainbow pattern — with blue, red, and purple areas. The clinical context (immunosuppression, multiple lesions, atypical distribution) usually raises suspicion.