Epidemiology and treatment of angiolymphoid hyperplasia with eosinophilia (ALHE): A systematic review

Nodular Vulvar Lesions

A woman in her 30s presented with mildly itchy skin nodules in the vulvar region for 1 year, which occurred during pregnancy and increased gradually in size and number without any treatments. What is your diagnosis?

Maxillary sinus angiolymphoid hyperplasia with eosinophilia associated to orbital and cutaneous lesion

INTRODUCTION

We describe the first case of ALHE in the orbit with extension to the maxillary sinus and the importance of a multidisciplinary approach to achieve removal of the lesion.

CASE STUDY

A 72-year-old man presented with epiphora of the left eye and several episodes of recurrent acute dacryocystitis. Magnetic resonance imaging revealed a solid homogeneous mass located in the inferomedial region of the left orbit. In addition, it was associated with destruction of the adjacent ethmoidal wall and upper wall of the left maxillary sinus. Incisional biopsy of the orbital mass was compatible with ALHE.

RESULTS

It was decided to perform surgery using an orbital floor approach, left medial wall via subconjunctival and caruncular approach together with an endoscopic nasal approach (ESS), achieving complete removal of the orbital mass and cleaning of the maxillary sinus. After one year of treatment, no tumor recurrence was evident through endoscopy and imaging tests and the patient is asymptomatic.

CONCLUSIONS

ALHE is a very rare benign vascular tumor that presents subcutaneous nodules in the head and neck region. We do not know of any case of ALHE in the paranasal sinuses described in the literature, either in isolation or together with orbital or cutaneous ALHE. In conclusion, ALHE disease should be considered as a diagnosis when faced with an orbital mass with extension to the paranasal sinuses, and a complete excision through a combined endonasal and orbital approach prevents recurrence in most cases.

Angiolymphoid hyperplasia with eosinophilia and Kimura disease: A case report and literature review

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign vascular proliferative condition, typically presenting as subcutaneous nodules in the head and neck region of middle-aged women. Kimura disease (KD) is a benign condition that presents with subcutaneous nodules in a similar distribution with lymphadenopathy and eosinophilia, typically in Asian adult males. These diseases are often discussed together, including whether they exist on a spectrum or if they represent separate disease entities. Both are very rare in the pediatric population; in this report we highlight the case of a 10-year-old Caucasian male presenting with ALHE and KD.

Epithelioid Hemangioma of the Popliteal Artery: A Case Report

An epithelioid hemangioma (EH) is a rare benign vascular lesion that is usually seen in superficial small vessels within the dermis and subcutaneous tissue. Intravascular epithelioid hemangiomas of large and medium-sized vessels are rare, and only a handful of cases have been reported in the literature. Intravascular epithelioid hemangiomas are biologically benign and best treated by complete surgical excision. On occasion, lesions have been associated with aneurysmal changes in the affected vessel. Local recurrence may occur, and close clinical follow-up is advised. Herein, we report the second case in the literature of an EH originating from the popliteal artery. A 57-year-old male patient presented with a one-month history of knee pain without claudication. Imaging highlighted a right popliteal aneurysm, 5x5 cm, with partial distal thrombosis and inadequate outflow. The patient subsequently underwent popliteal artery ligation above and below the aneurysm, reconstructed with a superficial femoral artery (SFA) to distal anterior tibial artery (ATA) reverse saphenous vein bypass graft. Patient recovery was complicated by the development of a 5x5 cm right-sided mid-thigh hematoma, requiring evacuation under anesthesia. A post-one-year arterial duplex of the affected limb demonstrated a recurrent enlarging popliteal aneurysm measuring 5.7x4.8x9.1 cm. The aneurysm was reported to be mostly thrombosed with noted vascularity, but patency of the original bypass was noted. The patient underwent excision of the recurrent aneurysm with subsequent ligation of the feeding arteries. Pathology and histology confirmed the final diagnosis of EH of the popliteal artery. An 18-month follow-up after the excision procedure demonstrated no recurrence of vascular lesion and patency of the original bypass graft.

Angiolymphoid Hyperplasia with Eosinophilia of the External Auditory Canal

Angiolymphoid hyperplasia with eosinophilia is a rare, benign, vaso-proliferative disease with a dense eosinophilic inflammatory infiltrate seen in the intradermal or subcutaneous region. It is also termed an epitheloid hemangioma, and it mostly affects females rather than males. It is seen as reddish to brown, fleshy, proliferative, papular, or nodular lesion affecting the head and neck region, most commonly the auricular and periauricular regions. The aetiology is unknown, but the most likely causes are trauma, infection, and hyperestrogenic condition like pregnancy or the use of oral contraceptive agents. It usually measures about 2-3 cm in size. It should be differentiated from Kimura disease, which is characterized by chronic inflammation and large subcutaneous nodules in the head and neck region. Here is a rare case report of angiolymphoid hyperplasia in a middle-aged male patient involving the external auditory canal of the left ear.

An Unusual Presentation of Angiolymphoid Hyperplasia with Eosinophilia as Postauricular Mass: A case Report

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare, benign, reactive vaso-proliferative condition in the dermal and subcutaneous tissues of the head and neck. A 28-year-old female presented with slow-growing painless swelling behind her left ear. FNAC revealed benign soft tissue neoplasm and histopathological examination after surgical excision revealed angiolymphoid hyperplasia with eosinophilia. ALHE origin has been variously attributed to prior trauma, hyperestrogenemia, infectious agents, atopy, reactive hyperplasia, and benign neoplasia. Retroauricular ALHE has been rarely reported. However, on the basis of our case report, it should be a viable differential diagnosis when large subcutaneous tumors of the head and neck are encountered. When big subcutaneous tumors of the head and neck are present, especially in females, a valid differential diagnosis for angiolymphoid hyperplasia with eosinophilia, a rare condition marked by dermal or subcutaneous endothelial cell proliferation, should also be considered.

Angiolymphoid Hyperplasia With Temporal Artery Eosinophilia: A Case Report

Angiolymphoid Hyperplasia with Eosinophilia (ALHE) is a benign vascular proliferative disorder with uncertain etiology and pathogenesis. The aim of this paper is to report a case of ALHE in the temporal artery and discuss the general aspects of this pathology. A 29-year-old female black patient sought the Vascular Surgery Outpatient Service, complaining of bulging in the right temporal region, associated with pain and local discomfort. Physical examination revealed pulsatile bulging in the right temporal region measuring approximately 2.5 × 1.5 cm. Nuclear Magnetic Resonance showed an expansive fusiform lesion in the superficial soft parts of the right temporal region, measuring 2.9 cm in the longest longitudinal axis. Surgical excision proved to be the best therapeutic option for the patient in this case. Histopathological sections showed the proliferation of vessels of different sizes, covered by swollen endothelium, prominent inflammatory infiltrate composed of lymphocytes, plasma cells, eosinophils, and scarce histiocytes. Immunohistochemical analysis of the lesion showed positivity for CD31, corroborating the diagnosis of ALHE.

An 8-year follow-up of IgG4-related skin disease presented with generalized ALHE-like eruptions: successful treatment of glucocorticoid and cyclophosphamide

Immunoglobulin gamma (IgG) type 4-related disease (IgG4-RD) is a chronic immunologic systemic disorder that could affect multiple organs, which may cause irreversible organ damage or even death. Skin involvement is rare and associated especially with systemic disease. The dermatologist must be equipped to recognize IgG4-RD to prevent delayed identification and treatment. This case reports a very rare case of IgG4-related skin disease (IgG4-RSD) presenting with a generalized angiolymphoid hyperplasia with eosinophilia (ALHE)-like lesions in a middle-aged male patient with no other organ involvement. He was treated with oral glucocorticoid and cyclophosphamide, which resulted in complete remission. No relapse and disease progression were seen with a follow-up for 8 years.

Recurrent Angiolymphoid Hyperplasia with Eosinophilia of the Parotid

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign vasculoproliferative disorder. It usually affects young adults presenting as papules or nodules involving the skin of head and neck region and rarely involves extracutaneous sites. ALHE involving parotid is rare and can be a diagnostic dilemma as it mimics a parotid neoplasm. This is a case of a 23 year old male presenting with a recurrent swelling over the left parotid region post surgery. Ultrasonography revealed a vascular soft tissue lesion in the preauricular region suggestive of a benign lesion. Contrast enhanced magnetic resonance imaging showed a hyperintense lesion involving the superficial lobe of the left parotid gland. Patient underwent superficial parotidectomy and histopathologically was diagnosed to have ALHE. Very few cases have been reported and this case is highlighted as the facial nerve was enmeshed by the intraparotid lesion which was a surgical challenge.

Multiple Eruptive Epithelioid Hemangiomas on the Right Upper Extremity in an Asian Man

Epithelioid hemangioma is a rare benign vascular neoplasm. Recently, the term "multiple eruptive epithelioid hemangioma" has been proposed for epithelioid hemangioma with distinct features. It is different from usual epithelioid hemangioma because of the multifocal distributions in various body regions with an eruptive onset. In addition, the histopathology of multiple eruptive epithelioid hemangioma shows increased cellular proliferation, mitosis, and nuclear pleomorphism and positive findings for FOS-B compared to classic epithelioid hemangioma. Herein, we report the case of a 59-year-old man with unusual manifestations suitable for multiple eruptive epithelioid hemangioma. He had multiple erythematous to purple-red dome-shaped nodules on the right hand, arm, and shoulder. The initial lesion was a solitary erythematous nodule on the right hand that abruptly extended to the right arm and shoulder. Microscopically, the tumor was a well-demarcated dermal nodule and showed capillary sized vascular structures. Vascular structures had epithelioid endothelial cells with abundant eosinophilic cytoplasm and vesicular nuclei. The tumor cells showed mild nuclear pleomorphism and a few mitosis and feature of resembling cobble stone was observed. In immunohistochemistry, CD31 and CD34 were positive in the endothelial cells. The endothelial cells showed nuclear positivity in FOS-B. Based on the clinical and histopathological findings, the final diagnosis was multiple eruptive epithelioid hemangiomas. This is the first report of multiple eruptive epithelioid hemangiomas in an Asian man after the term had been introduced.

[Multiple, eruptive epithelioid hemangiomas of the scalp]

Epithelioid hemangioma is a benign vascular neoplasm with a characteristic histological and immunohistochemical pattern, characterized by a lymphocytic inflammatory infiltrate with admixed eosinophils and FOS‑B expression. The correct diagnosis is of particular relevance, since malignant vascular tumors with differentiated epithelioid cells can also be considered in the differential diagnosis. We present a patient with multiple epithelioid hemangiomas of the scalp accompanied by severe pain and itching. The long history of multiple therapeutic attempts illustrates the limited success of currently available treatment options.

Cutaneous vascular tumors: an updated review

Cutaneous vascular tumors constitute a heterogeneous group of entities that share overlapping morphologic and immunohistochemical features, which can be diagnostically challenging for pathologists and dermatopathologists. Our understanding and knowledge of vascular neoplasms have improved over time, resulting in both a refinement of their classification by the International Society for the Study of Vascular Anomalies (ISSVA) and an improvement in the accurate diagnosis and clinical management of vascular neoplasms. This review article aims to summarize the updated clinical, histopathological, and immunohistochemical characteristics of cutaneous vascular tumors, as well as to highlight their associated genetic mutations. Such entities include infantile hemangioma, congenital hemangioma, tufted angioma, spindle cell hemangioma, epithelioid hemangioma, pyogenic granuloma, Kaposiform hemangioendothelioma, retiform hemangioendothelioma, pseudomyogenic hemangioendothelioma, Kaposi sarcoma, angiosarcoma, and epithelioid hemangioendothelioma.

Angiolymphoid Hyperplasia of the External Auditory Canal; Reconstruction of a Complex Defect

Angiolymphoid hyperplasia (AH) was first described by Wells and Whimster in 1969 as a benign vasoproliferative pathology with a varied infiltrate of eosinophils, lymphocytes, and plasmatic cells. Clinical presentation has been described in the literature as small red-bluish nodules, less than 3 cm in diameter that can bleed in 25% of the cases and be pruritic and painful in 37% and 20% of the cases, respectively. Particularly, AH can appear in the ear; nevertheless, other regions have been affected, including the scalp, lips, tongue, orbit, muscle, and bone. Most of these cases have occurred in adults with an unknown etiology; however, an inflammatory process has been associated in approximately 20% with eosinophilia. No malignancy has been reported.

A Rare Case of Angiolymphoid Hyperplasia With Eosinophilia With a New Effective Treatment

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign locally proliferating lesion of unknown etiology, composed of vascular channels lined by endothelial cells, surrounded by lymphocytes and eosinophils. It presents clinically as a cluster of skin to violaceous-colored nodules on the head and neck, particularly in and around the ear. We present the case of a 50-year-old, Pakistani woman with unilateral multiple nodular lesions for eight years in the left ear concha and postauricular area causing complete obliteration of the external auditory meatus with conductive hearing loss of the left ear for seven years. Biopsy showed lymphoid follicles and dilated blood vessels with mixed infiltrate predominantly eosinophils corresponding to the diagnosis of angiolymphoid hyperplasia with eosinophilia. Surgical excision was not feasible, and there was no response to topical steroids. The patient was started on beta blockers. After three months, postauricular lesions completely resolved, and the size of the rest of the nodules decreased markedly; then hearing loss also recovered. Our objective in this study is to emphasize the importance of considering beta blockers for the treatment of ALHE.

Angiolymphoid Hyperplasia of the Orbit: A Rare Case Report and Review of the Literature

Background: Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare vascular tumour of the skin which mainly involves the head and neck regions. Case Report: A 41 year old male presented to the ENT outpatient department with a swelling in the anterosuperomedial aspect of right orbital rim since two year. Following a contrast enhanced CT of the Head, complete surgical excision was done and diagnosis of ALHE was confirmed by histopathology. Methodology: We performed a systematic review of the literature following the preferred reporting items for Systematic reviews. Literature searches were conducted in web based search engines using MeSH terms and key words. We found seven publications that fit the inclusion criteria which included case reports and case series. Conclusion: ALHE involving the orbit has been very rarely reported and is a challenging diagnosis. Complete surgical excision is the treatment of choice and recurrence can occur with incomplete removal.

Atypical Presentation of Kimura’s Disease in a Male Patient: A Case Report and Review of Literature

Kimura’s disease (KD) is a rare chronic inflammatory condition of unknown aetiology. It is a benign disease that might mimic a neoplastic process. It primarily affects the head and neck region, presenting as deep subcutaneous masses, and is often accompanied by triad regional lymphadenopathy, salivary gland involvement, and high serum immunoglobulin E (IgE) levels. Here, we report the second documented case of KD in Palestine diagnosed in a 28-year-old male patient who presented with lymphadenopathy and increased serum immunoglobulin E and G (IgE and IgG) associated with intermittent abdominal pain, generalised fatigue, hepatomegaly, cardiomyopathy, reactive airway disease, peripheral vasculopathy, peripheral neuropathy, and focal segmental glomerulosclerosis. The patient was managed with steroids and an immunosuppressant (Azathioprine) with a moderate response for two years. In 2021, treatment with Mycophenolate Mofetil was initiated, which was more effective than Azathioprine.

Refractory angiolymphoid hyperplasia with eosinophilia: Complete resolution with low dose thalidomide

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a difficult-to-treat and rare benign vascular proliferative condition which presents as painless, solitary, or multiple vascular papules or nodules in the head and neck area, with predilection for the ear. We report a case of ALHE that failed multiple therapeutic interventions but achieved complete resolution when treated with thalidomide.

Cutaneous Reactive B-cell Lymphoid Proliferations

Cutaneous lymphoid hyperplasia (CLH), also known as cutaneous pseudolymphoma, is a spectrum of benign conditions characterized by reactive B- and T-cell cutaneous lymphocytic infiltrates. B-cell lymphoid proliferations are a heterogenous group of non-neoplastic cutaneous diseases that must be histopathologically distinguished from cutaneous B-cell lymphomas. These proliferations can be observed as reactive phenomena to infections, medications, allergens, neoplasms, and more. Further, there are many inflammatory conditions that present with reactive B-cell infiltrates, including actinic prurigo, Zoon balanitis, Rosai-Dorfman, and cutaneous plasmacytosis. This review summarizes multiple cutaneous B-cell lymphoid proliferations within the major categories of reactive and disease-associated CLH. Further we discuss major discriminating features of atypical CLH and malignancy. Understanding the specific patterns of B-cell CLH is essential for the proper diagnosis and treatment of patients presenting with such lesions.

Kimura's disease successively affecting multiple body parts: a case-based literature review

Background

Kimura’s disease is a rare, benign, chronic inflammatory disease that presents as painless, solid masses mainly affecting the deep subcutaneous areas of the head and neck, especially the salivary glands, parotid glands and nearby lymph nodes. It is characterized by elevated peripheral blood eosinophil and Immunoglobulin E (IgE) levels.

Case presentation

A 31-year-old Asian male presented with an orbital space-occupying lesion lasting for 1.5 years. Ten years prior, surgical excision of bilateral fossa cubitalis and groin masses was performed, and the pathological examination showed "lymphoproliferative disease". One year later, masses reappeared near the surgical sites; they grew slowly and shrank after glucocorticoid treatment. At this point, admission examinations showed in the peripheral blood an eosinophil proportion of 13.4%, a total IgE level of 26,900.00 IU/mL, prurigo present on the whole body, and multiple palpable masses near the bilateral fossa cubitalis and groin. The left eyeball was exophthalmic. The left elbow mass was excised, and the pathological examination confirmed Kimura’s disease. Oral glucocorticoid therapy is taken and tapering regularly. The eosinophil count returned to normal, the IgE level gradually decreased, the orbital space-occupying lesion and elbow and groin masses shrank significantly, and the whole-body skin prurigo disappeared. Currently, the patient has been in a stable condition for eighteen months.

Conclusion

Our case provides a novel insight that Kimura’s disease should be involved in the differential diagnosis of inflammatory lesion mass of orbit and also supports systemic regular glucocorticoid as a valuable therapy of such condition, but close follow-up and long-term observation are crucial.

[The most common benign cutaneous neoplasms of vascular, muscular, and adipose tissue and their treatment]

Benign cutaneous vascular and cutaneous neoplasms arising from muscle or adipose tissue are rare. Their definition and classification are still controversially discussed. Histopathological and immunohistochemical studies, together with the new genetic tests, contribute significantly to the correct description of the various benign neoplasms of cutaneous origin. Clarifying whether a lesion is benign is fundamental for prognosis and therapeutic management. In most cases, surgical excision is the treatment of choice. Dermatologists should be familiar with the classifications of the most common benign cutaneous neoplasms of vascular, muscular, and adipose tissue and be able to recommend the procedures currently used for an accurate diagnosis. Ensuring that a lesion is benign and a good surgical outcome are essential for the patient.

Percutaneous ethanol sclerotherapy is a promising treatment for recalcitrant angiolymphoid hyperplasia with eosinophilia

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign vascular proliferation, which manifests as characteristic red nodules and papules, mostly located on the scalp and periauricular regions. Patients seek treatment for both aesthetic and functional reasons, as lesions may ulcerate, bleed and itch. Many therapeutic approaches have been reported, with variable success, and relapse remains a troublesome issue. The aim of this study was to report our experience treating ALHE using percutaneous ethanol sclerotherapy (PES). We present a retrospective case series of three patients treated with PES (1-2 treatment sessions each). All patients had tried and failed other treatments prior to this intervention, but following PES treatment, all patients demonstrated significant improvement, which was sustained at follow-up (range 8-17 months after first treatment). Adverse effects were tolerable and transient. This case series demonstrates PES as a promising treatment for recalcitrant ALHE.

Comparison between Kimura's disease and angiolymphoid hyperplasia with eosinophilia: case reports and literature review

Kimura’s disease (KD) is a rare chronic inflammatory or allergic disease. Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign vascular neoplasm. Their relationship has always been debated. This article reports two rare cases, one of each disease. One patient was a 48-year-old female that presented with a mass on her right mandible. She also had oedema erythema and wheals on her lower limbs. She was diagnosed with Kimura’s disease complicated with chronic urticaria. The second patient was a 23-year-old female that presented with multiple nodules of unequal size on the scalp. She was diagnosed with angiolymphoid hyperplasia with eosinophilia. The first patient recovered after being treated with surgical resection, glucocorticosteroids, cyclophosphamide and radiotherapy. The second patient underwent the first stage of surgical excision and is currently being followed-up. Comparison of the clinical and histopathological features of these two cases supports the theory that KD and ALHE are two separate disease entities.

Assessing the compliance of systematic review articles published in leading dermatology journals with the PRISMA statement guidelines: A systematic review

Background

Reporting quality of systematic reviews and meta-analyses is of critical importance in dermatology because of their key role in informing health care decisions.

Objective

To assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines.

Methods

This review was carried out in accordance with PRISMA guidelines. Included studies were reviews published across 6 years in the top 4 highest-impact-factor dermatology journals of 2017. Records and full texts were screened independently. Data analysis was conducted with univariate multivariable linear regression. The primary outcome was to assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the PRISMA statement.

Results

A total of 166 studies were included and mean PRISMA compliance across all articles was 73%. Compliance significantly improved over time (β = .016; P = <.001). The worst reported checklist item was item 5 (reporting on protocol existence), with a compliance of 15% of articles.

Conclusion

PRISMA compliance within leading dermatology journals could be improved; however, it is steadily improving.

Spontaneous regression of angiolymphoid hyperplasia with eosinophilia (AHLE): A case report

Introduction

and importance - Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign microvascular proliferation. It is clinically characterized by intradermal or subcutaneous papules and/or nodules. Treatment consists mainly of surgery or laser therapy, with a high recurrence rate. Spontaneous regression is rare but possible.

Case presentation

A 72-year-old man presented for an erythematous plaque on his scalp. Physical examination demonstrated a large angiomatous indurated subcutaneous plaque. The lesion was not pulsatile. The doppler ultrasound revealed no underlying vascular malformation. The biopsy revealed an ALHE. No further treatment was carried out. During the follow-up, the lesion gradually subsided. After one-year follow-up, the lesion had regressed with no sign of recurrence.

Clinical discussion

There are different treatment modalities for AHLE management, including surgical excision, cryotherapy and lasers. However, none of these modalities has provided consistent results and recurrence after treatment is common.). Rare instances of spontaneous regression have been reported.

Conclusion

Given the rarity of cases of spontaneous resolution, ALHE may be considered as a chronic condition, especially since recurrences are frequent. A “wait and see” approach can be proposed in some specific situations.

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AHLE is a rare benign microvascular proliferation.

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Treatment consists of surgery or laser therapy, with a hight recurrence rate.

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Spontaneous regression is rare but possible.

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We report a case and review the literature of spontaneously regressive ALHE cases.

Angiolymphoid hyperplasia with eosinophilia attached to the masseter muscle

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign vascular tumor. The pathogenesis of ALHE is unknown; however, it may be linked to local trauma. ALHE predominantly occurs in areas of the preauricular region, forehead, and scalp; the masseter area is rarely involved. A 49-year-old man was referred for a mass in the right cheek region that was felt 2 months prior. Physical and imaging examination results suggested the presence of a benign tumor. Thus, surgical excision was performed. Pathologic findings confirmed an unexpected diagnosis of ALHE. This case was interesting, since the mass occurred at an unusual site with a misdiagnosis of an epidermal inclusion cyst.

Immunoglobulin-G4-related skin disease

Immunoglobulin-G4-related disease (IgG4-RD) is an autoimmune-mediated spectrum of diseases, characterized by infiltration of IgG4+ plasma cells into one or multiple organs, with the pancreas being the most commonly affected organ. The disease mostly affects middle-aged to elderly men. Diagnosis requires an integration of clinical, radiologic, pathologic, and serologic studies. Histologically, there is an increased infiltration of IgG4+ plasma cells, elevated ratio of IgG4+/IgG plasma cells of more than 40%, and a storiform pattern of fibrosis. There may be eosinophilia, along with elevated IgG4 levels. IgG4-RD can mimic several diseases and should be differentiated from inflammatory and neoplastic processes. Recently, there has been increased awareness of cutaneous involvement by IgG4-RD either as an isolated lesion or primary involvement or as a secondary involvement from a systemic disease. Clinically, cutaneous IgG4+-related disease presents as papules, plaques, and nodules involving the head and neck areas. We have provided a systematic review of the literature of this new and challenging entity of cutaneous IgG4-RD.

Inflammatory lobular hemangioma: A vascular proliferation with a prominent lymphoid component. Review of a series of 19 cases

In the last 30 years, there has been a strong interest in vascular proliferations. Pyogenic granuloma was not only renamed lobular capillary hemangioma, but also the conceptual interpretation was also changed from an overgrowth of granulation tissue to a genuine hemangioma (or benign vascular neoplasm). We describe 19 cases of patients who presented clinically with a vascular lesion, characteristically a pyogenic granuloma or lobular hemangioma, where the histopathological findings led to the pathologic concern for a lymphoma of the skin. These benign lesions with a dense lymphoid infiltrate were further defined on the basis of different vascular and lymphoid immunohistochemical markers as inflammatory lobular hemangiomas. We propose that given the considerable histopathological overlap between acral pseudolymphomatous angiokeratoma, T-cell rich angiomatoid polypoid pseudolymphoma of the skin, and other designations of some of these vascular proliferations with a rich and dense lymphoid infiltrate, they might constitute a spectrum of vascular lesions with varying clinical presentations.

Cytologic features of angiolymphoid hyperplasia with eosinophilia: Highlighting the diagnostic clues

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon, benign, inflammatory disorder involving the skin and microvasculature with an undetermined etiopathogenesis. Although the histopathology is well-characterized, the cytologic features of this entity have been rarely described in literature. This study was conducted to describe in detail the cytomorphologic features of ALHE and to identify the characteristic features that can help in establishing a correct diagnosis of this entity. This was a retrospective study conducted over a period of 3 years, wherein the corresponding cytologic smears of histopathologically diagnosed cases of ALHE were retrieved and reviewed. All the cytologic features were recorded to identify characteristic features that can be used to differentiate ALHE from other cytologic mimics. On histopathologic examination, 15 cases were reported as ALHE. Corresponding cytologic samples were available for three cases. All the three cases were males who were 21, 22 and 52 years old, respectively. The sites of the swellings were scalp, orbital and preauricular. The most consistent cytologic findings were the presence of eosinophilia, scattered plump endothelial cells and a reactive lymphoid background. We believe that a thorough cytologic examination for the presence of plump to spindle-shaped cells in smears with eosinophilia and reactive lymphoid tissue, can help in reaching to a cytologic diagnosis of ALHE in suspected cases.

Eosinophilic Dermatoses: Recognition and Management

Eosinophilic dermatoses encompass a broad spectrum of diseases of different etiologies hallmarked by eosinophilic infiltration of the skin and/or mucous membranes, with or without associated blood eosinophilia. The wide range of dermatological manifestations of this spectrum, including nodules and plaques, pustules, blisters, ulcers, and urticarial lesions, is reflected in a non-univocal classification system. We identified six groups of eosinophilic dermatoses based on the predominant anatomic level of involvement: (1) epidermal; (2) of the dermal-epidermal junction; (3) dermal; (4) of the hypodermis and muscle fascia; (5) of the pilosebaceous unit; and (6) vascular/perivascular. We review clinicopathologic features and management of diseases belonging to each group, particularly: (1) pemphigus herpetiformis and atopic dermatitis as prototypes of the epidermal group; (2) bullous pemphigoid as prototypic eosinophilic dermatosis of the dermal-epidermal junction; (3) eosinophilic cellulitis (Wells syndrome), hypereosinophilic syndromes, Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, eosinophilic dermatosis of hematologic malignancy and chronic spontaneous urticaria as paradigmatic dermal eosinophilic dermatoses; (4) eosinophilic fasciitis as an eosinophilic dermatosis with predominant involvement of the hypodermis and muscle fascia; (5) eosinophilic pustular folliculitis as a model of the pilosebaceous unit involvement; and (6) granuloma faciale, angiolymphoid hyperplasia with eosinophilia, and eosinophilic granulomatosis with polyangiitis, belonging to the vascular/perivascular group.

Angiolymphoid Hyperplasia with Eosinophilia Located on the Forehead: A Possible Association with Oral Contraceptive Use?

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign vasoproliferative tumor characterized by nodules, papules or plaques localized principally in the head and neck region. Histopathological examination reveals hyperplastic blood vessels lined by large endothelial cells, accompanied by an infiltrate of inflammatory cells including eosinophils. The pathogenetic mechanism remains unclear, although different theories have been proposed. Various treatment strategies have been described, but surgery remains the treatment of choice. We describe the case of a young woman with ALHE taking an oral contraceptive pill suggesting a possible etiopathogenetic relationship.

Benign Subcutaneous Nodules and Hypereosinophilic Syndrome: A Rare Presentation of an Uncommon Entity

A 40-year-old gentleman presented with a history of multiple swellings involving his face, scalp, left axilla, back, and right thigh for the past 8 years. For the last 6 months, he developed intermittent low-grade fever, anorexia, weight loss, and gradually worsening breathlessness. On evaluation, the patient was found to have abnormally elevated absolute eosinophil count. Workup for the etiology of eosinophilia was unrewarding. All investigations related to an underlying myeloproliferative disorder were negative. Hence, a clinical possibility of angiolymphoid hyperplasia with eosinophilia (ALHE) was kept which was confirmed on histopathology. In the absence of other causes of hypereosinophilia, a clinical diagnosis of “associated hypereosinophilic syndrome” secondary to ALHE was made. He was managed with oral corticosteroids. The absolute eosinophil count reduced markedly, while the swellings showed a more gradual response, shrinking in size by about 50% following two months of therapy. The index case thus highlights a rather unusual presentation of ALHE.

Angiolymphoid Hyperplasia With Eosinophilia: New Concept to Lower Recurrence

Angiolymphoid Hyperplasia with Eosinophilia (AHLE) is a rare benign vascular disorder of unknown etiology. While World Health Organization recognizes it as a benign neoplasm, its progressive nature and high recurrence rate are consistent with being a locally malignant tumor. It may present as solitary or multiple nodules with more predilection to head and neck region, especially auricular area. Despite variety of available treatment options, high recurrence rate remains a compelling issue. The spectrum of these treatment modalities includes topical or systemic steroids use, intralesional injection of certain materials such as Bleomycin, Vinblastine or interferon, or even surgical excision.In our study, the authors present a case of middle-aged female with recurrent AHLE in left concha and preauricular region. Excision of the lesion with 4 mm of the normal surrounding skin, preserving auricular cartilage, was done while the resultant defect was covered by grafted Temporoparietal Fascia Flap. Our 1-year follow-up period showed aesthetically accepted outcome with no recurrence.The authors hypothesize that treating AHLE as a locally malignant tumor by excising the lesion with 4 mm safety margin decreases recurrence rates. Moreover, reconstruction by grafted temporoparietal fascia flap achieves a reasonable aesthetic outcome with minimal donor site morbidity.

Nonvascular uses of pulsed dye laser in clinical dermatology

Lasers are fast becoming the vogue of dermatology ranging from ablative, nonablative, fractional photothermolysis to vascular lasers. There are a range of vascular lasers including potassium titanyl phosphate (KTP 532 nm), pulsed dye laser (PDL -595 nm), diode (810 nm), and Nd:YAG (1064 nm). PDL is a laser that emits yellow light using Rhodamine dye as it is lasing medium. Typical vascular lesions which are treated by PDL include port wine stain, hemangioma, telangiectasia, spider angioma, and rosacea. This article focuses on the use of PDL beyond primary vascular conditions. We review the evidence, or lack thereof, of the use of PDL in acne vulgaris, scars, striae, warts, molluscum, psoriasis, rejuvenation, basal cell carcinoma (BCC), and miscellaneous dermatological sequelae.

Combination of electrocoagulation and photodynamic therapy for angiolymphoid hyperplasia with eosinophilia in the external ear

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an inflamed vascular tumefaction of uncertain pathogenesis and is characterized by higher recurrence rates after surgical excision or other approaches. In the present study, we performed a new approach by combining electrocoagulation with photodynamic therapy (PDT) for the treatment of two ALHE patients. They had multiple treatments in the past and had poor therapeutic effects with relapse each time. After informed consent was obtained, electrocoagulation was used to remove the superficial lesions of ALHE, and the first session of PDT was immediately applied to the lesion. A total of three sessions of PDT were applied to each patient with an interval of 7-10 days. Through more than 12 months of follow-up, the two patients showed complete regression, and no recurrence was observed. Meanwhile, patients were very satisfied with the cost and cosmetic outcomes of the combination treatment. Based on our results, we strongly recommend the combination of electrocoagulation with PDT as a favourable treatment for ALHE, especially in the external ear and other areas that are inconvenient for routine surgery.