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A Rare Case of Angiolymphoid Hyperplasia With Eosinophilia: A Dermoscopic and Therapeutic Teaching Point

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Case Presentation

A 45-year-old Caucasian woman referred to us for a 2-year history of multiple, intensely itchy, red-purple papulonodular skin lesions located on the occipital area of her scalp ( Figure 1A ). The lesions were firm to palpation, measuring from 0.5 to 1 centimeter in diameter. The patient had no significant past medical history and denied any history of trauma or systemic infection. Topical treatment with potent corticosteroids resulted in no improvement. Dermoscopy showed red clods on the scratched lesions and dotted and peripheral linear unfocused vessels on pink-whitish structureless area ( Figure 1, B and C ).

A punch biopsy was performed, and the histological examination revealed pathognomonic features leading to the diagnosis of angio-lymphoid hyperplasia with eosinophilia (ALHE) ( Figure 1D ).

Several treatments with a combination of CO 2 and dye laser were performed leading to debulking of the lesions and the treatment of the vascular component. Our treatment protocol involved two laser sessions with a 5-weeks interval. In the first session, each laser treatment was performed in continuous wave mode at 3 W/cm 2 . Vaporized debris was removed using a cotton-tipped applicator soaked in saline solution. In the same session, a second pass was performed in focalized mode at 3 W/cm 2 . For the Dye laser, we used a 7 mm spot size, 1.5 ms pulse duration, and fluence of 12.0 J/cm 2 . Both treatments were well tolerated, and no complications were reported. After surgery, fusidic acid ointment and a mild pressure dressing were applied; the patient was instructed to apply the ointment to the treated area for 7 days.

The patient was evaluated every 3 weeks with important improvement of her symptoms and minimal scarring ( Figure 1E ).

Teaching Points

ALHE is a rare idiopathic vascular disorder of unknown etiopathogenesis characterized by the presence of red-purple papules located in the head and neck area.

Dermoscopy of ALHE is unspecific and may show a pattern characterized by red clods, pink-whitish background and polymorphous vascular pattern consisting of dotted, globular and linear vessels [ 1 ] . In our opinion, the red rather than pink color may be related to traumatic scratching of lesions, and lesions at different stages may coexist in the same patient.

The main differential diagnoses include Kimura disease, lichen planus, kaposi sarcoma, and molluscum contagiosum. The histological features of ALHE are the clue for the diagnosis and biopsy should be performed in all cases in which doubtful dermoscopic finding.

Treatment options mainly includes surgical excision of the lesions, cryotherapy or laser ablation. In ALHE recurrences may occur and multiple treatments and follow up are mandatory [ 2 ] .

References

  1. Dermoscopic Features of Two Cases of Angiolymphoid Hyperplasia with Eosinophilia and Review of the Literature Akay BN, Fatih Atak M, Farabi B. Dermatol Pract Concept.2021;11(2):e2021003. CrossRef PubMed
  2. Comparison between Kimura’s disease and angiolymphoid hyperplasia with eosinophilia: case reports and literature review Zou A, Hu M, Niu B. J Int Med Res.2021;49(9). CrossRef PubMed

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