diffuse dermal angiomatosis ( dda ) is a benign , acquired , reactive vascular proliferation ; it is a variant of reactive angioendotheliomatosis . dda is characterized by painful , violaceous , purpuric and occasionally ulcerated plaques mainly on the lower extremities of patients with peripheral vascular atherosclerotic disease . , he had also had intermittent claudication of both legs , the right being worse . his medical history was significant for coronary artery disease , diabetes mellitus , dyslipidemia , hypertension and heavy smoking . medications included aspirin ( 325 mg / day ) , isosorbide dinitrate , glipizide , simvastatin , carvedilol and hydralazine . physical examination revealed a solitary , well - defined , stellate - shaped purpuric patch , 10  12 cm , on the right thigh , with a superficial central ulceration covered by a hemorrhagic crust ( fig . femoral , popliteal , posterior tibial and dorsalis pedis pulses were absent on both sides . histopathology showed interstitial proliferation of spindle cells in association with extravasated red blood cells and sparse perivascular inflammatory cell infiltration in the dermis without intravascular proliferation ( fig . computed tomography angiography showed total occlusion of the right infrarenal aorta extending to the aortic bifurcation , both common iliac arteries and the internal and external iliac arteries ( fig . our patient underwent right axillo - femoral and left femoro - femoral bypass surgery , along with tight control of cardiovascular risk factors , which yielded successful results . the painful lesion rapidly disappeared within 1 week after the operation , leaving postinflammatory hyperpigmentation and a central reticulate scar . dda is a benign vascular disorder of the skin , classified in the group of cutaneous reactive angiomatosis . it has been described in association with atherosclerotic peripheral vascular disease . it is hypothesized that ischemia or inflammation generates a local hypoxic stimulus , which results in increased vascular endothelial growth factor , endothelial proliferation and neovascularization . in addition , vascular occlusion caused by atherosclerotic plaques may be a source of emboli to distal cutaneous vessels , where they could induce neoangiogenesis . the clinical presentations of dda consist of erythematous to violaceous , livedoid patches , often with central ulceration . the lesions may be solitary or multiple and are typically found on the lower extremities in patients with severe atherosclerotic disease . dda has been reported on the forearm secondary to iatrogenic arteriovenous fistulas in chronic hemodialysis patients and in women with nonhealing , ulcerating lesions on the breast [ 3 , 4 ] . in addition , this cutaneous reactive pattern has also been reported in association with a variety of diseases that cause vasculopathy , including calciphylaxis [ 5 , 6 ] , monoclonal gammopathy [ 7 , 8 ] and cutis marmorata telangiectatica congenita . the differential diagnosis of dda includes vasculopathy , medium to large vessel vasculitis , acroangiodermatitis and benign or malignant vascular tumor . histologically , dda is characterized by diffuse proliferation of endothelial cells interstitially arranged between collagen bundles within the dermis . frequently , the proliferating cells may show a spindled morphology , vacuolated cytoplasm and formation of small vascular channels , suggesting neoangiogenesis immunohistochemistry shows positivity of endothelial cells for ulex europaeus agglutinin-1 , factor viii - associated antigen , cd31 and cd34 [ 3 , 5 ] . however , cytologic atypia , diffuse slit - like lumen formation and the promontory sign along with the inflammatory component are lacking . acroangiodermatitis , by contrast , exhibits slight endothelial proliferation and formation of new thick - walled vessels in a lobular arrangement in the dermis . we performed a pubmed search using the term  diffuse dermal angiomatosis and found 29 cases in the english language literature , of which 11 were associated with peripheral artery disease ( table 1 ) . the characteristic clinical features of the reported patients were reticulated , erythematous to purpuric plaque with central necrotic area . in addition , all reported patients had multiple atherosclerotic comorbidities such as hypertension , dyslipidemia , diabetes mellitus , chronic kidney disease and heavy smoking . most of them had undergone revascularization procedures , and all lesions rapidly healed shortly after the procedures [ 2 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ] . however , one reported patient who received conservative medical therapy , which included oral prednisolone and colchicine , died from severe sepsis . revascularization , such as vascular surgery for correcting and bypassing the vascular occlusion , is the most efficient method , particularly in cases caused by vaso - occlusive disease , and generally results in complete or near - complete lesion resolution . systemic steroids and isotretinoin have been successfully used as well , based on their inhibitory effect on neoangiogenesis . it should be considered in a patient who presents with painful , nonhealing purpuric plaque with central ulceration on the upper thigh . prompt recognition is important as surgical intervention is often curative , thereby limiting the associated morbidity . the authors declare that they have no conflict of interest and that they received no funding .
diffuse dermal angiomatosis ( dda ) is a benign , acquired , reactive vascular proliferation . 
 dda is clinically characterized by painful purpuric plaque with central ulceration . 
 the histopathologic hallmark is diffuse proliferation of endothelial cells that are arranged interstitially between collagen bundles of the reticular dermis . 
 dda has been reported in association with peripheral atherosclerotic disease , arteriovenous fistula and heavy smoking . 
 we report the case of a 49-year - old asian male with dda who presented with a painful stellate - shaped purpuric patch on the right thigh . 
 histopathologic examination showed proliferation of cd34-positive spindle cells in the dermis . 
 our patient underwent vascular bypass surgery along with tight control of cardiovascular risk factors , which yielded successful results .