Dermatology: Practical and Conceptual Letter | Dermatol Pract Concept 2021;11(2):e2021003 1 Dermatology Practical & Conceptual Dermoscopic Features of Two Cases of Angiolymphoid Hyperplasia with Eosinophilia and Review of the Literature Bengu Nisa Akay1, Mehmet Fatih Atak1, Banu Farabi1,2 1 Dermatology Department, Ankara University School of Medicine, Turkey 2 Dermatology Department, Rutgers University, Robert Wood Johnson Medical Center, New Jersey, USA Key words: angiolymphoid hyperplasia with eosinophilia, red clods, dermoscopy Citation: Akay BN, Fatih Atak M, Farabi B. Dermoscopic features of two cases of angiolymphoid hyperplasia with eosinophilia and review of the literature. Dermatol Pract Concept. 2021;11(2):e2021003. DOI: https://doi.org/10.5826/dpc.1102a03 Accepted: July 26, 2020; Published: March 8, 2021 Copyright: ©2021 Akay et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Banu Farabi, MD, Rutgers University, Robert Wood Johnson Medical Center, New Brunswick, NJ, USA. Email: banufarabi91@gmail.com Introduction Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign vascular tumor that typically presents as papules or nodules that are pink or dull red in color and are located predominantly in the head and neck region. Mural damage or rupture of large intralesional vessels suggest that trauma or arteriovenous shunting may play a etiological role, and a history of trauma can be elicited in some patients. The lesions may be asymptomatic or may be painful, pruritic, bleeding or pulsatile. Some patients have regional lymph node enlarge- ment and peripheral eosinophilia. Clinical diagnosis of this entity can be challenging espe- cially in atypical presentations and dermoscopy might be helpful when considring ALHE as a differential diagnosis. To date, dermoscopic features of ALHE have been described in 3 cases [1,2]. Herein, we present 2 cases of ALHE with their dermoscopic features. Case Presentations The reported characteristics and dermoscopic findings of our patients are presented in Table 1. Clinical and dermoscopic images are shown in Figure 1. Both of our patients’ diagnoses have been confirmed by histopathological examination. Discussion ALHE is a rare benign vasoproliferative disorder of unknown origin. Various hypotheses have been described including prior trauma, reactive hyperplasia, benign neoplasia, hypere- strogenemia, infectious agents, and atopy. Although ALHE is a benign entity, it can be confused with many conditions including sarcoidosis, lymphocytoma cutis, Kaposi sarcoma, angiosarcoma and metastatic tumors clinically. Therefore, biopsy is often required for diagnosis. 2 Letter | Dermatol Pract Concept 2021;11(2):e2021003   A g e (Y e a rs ) S e x Lo ca ti o n D u ra ti o n C li n ic a l Fe a tu re s P re ce d in g T ra u m a D e rm a to sc o p y C B C a n d U S G F in d in g s C as e 1 4 6 F em al e R ig h t p o st er io r au ri cu la r ar ea 3 m o n th s A sy m p to m at ic , m u lt in o d u la r, re d d is h l es io n N o h is to ry o f tr au m a L ar ge s iz ed r ed c lo d s w it h ra n d o m ly a rr an ge d s h o rt w h it e li n es a n d r eg u la r d o tt ed ve ss el s o ve r ea ch c lo d N o rm al C as e 2 3 5 M al e L ef t p re au ri cu la r ar ea 8 m o n th s P ru ri ti c, m u lt ip le p in k -c o lo re d p ap u le s N o h is to ry o f tr au m a A f o ca l ar ea c o m p o se d o f re d c lo d s, p in k -b ro w n st ru ct u re le ss a re as w it h se rp en ti n e an d l o o p ed v es se ls , su b tl e w h it e li n es N o rm al R o d ri gu ez -L o m b a et a l. C as e 1 4 5 M al e In n er a sp ec t o f th e le ft th ig h 6 m o n th s A sy m p to m at ic , en la rg in g, p in k - co lo re d n o d u le N o t m en ti o n ed P o ly m o rp h o u s va sc u la r p at te rn c o m p o se d o f d o tt ed , co rk sc re w , a n d i rr eg u la r- li n ea r ve ss el s ar ra n ge d ra d ia ll y o ve r a d if fu se p al e re d d is h b ac k gr o u n d N o t m en ti o n ed R o d ri gu ez -L o m b a et a l. C as e 2 1 7 F em al e F ro n t o f th e n ec k R ec en t o n se t A sy m p to m at ic , p in k -c o lo re d m u lt in o d u la r p ro li fe ra ti o n N o t m en ti o n ed D o tt ed a n d i rr eg u la r ve ss el s re gu la rl y d is tr ib u te d w it h in ea ch n o d u le o ve r a d if fu se li gh t p in k b ac k gr o u n d N o t m en ti o n ed Sa n to sa e t al . 5 5 M al e N o se 7 m o n th s B le ed in g, 5 -m m d ia m et er l es io n w it h s o li ta ry u lc er E le ct ro ca u te ry p er fo rm ed t o t h e le si o n c o n si d er ed k er at o ac an th o m a, 1 ye ar p re vi o u sl y M u lt ip le d o tt ed v es se ls an d c en tr al u lc er at io n w it h ad ja ce n t w h it e ar ea N o t m en ti o n ed C B C = c o m p le te b lo o d c o u n t; U SG = u lt ra so n o gr ap h y. Ta b le 1 . C o m p ar is o n o f C as e 1 a n d C as e 2 w it h C u rr en t C as es R ep o rt ed i n t h e L it er at u re Letter | Dermatol Pract Concept 2021;11(2):e2021003 3 Figure 1. Clinical and dermoscopic pictures of angiolymphoid hyperplasia with eosinophilia. (A) A 46-year-old woman with a multinodular reddish lesion on the right posterior auricular area. (B) Dermoscopic image shows red clods with dotted vessels, subtle white lines and pink structureless areas. (C) A 34-year-old man with multiple pink-colored papules in the left preauricular area. (D, E) Dermoscopic images show a focal area of red clods and subtle white lines and a peripheral brown structureless area. Dermoscopic features of ALHE are described in 2 case reports [1,2]. Rodriquez et al. observed a polymorphous vas- cular pattern consisting of dotted and linear vessels on a pale reddish to pinkish background [1]. Santosa et al. described a clinical mimicker of keratoacanthoma, showing a central keratin mass and ulceration surrounded by dotted, globular and linear irregular vessels on dermoscopy [2]. In our first case case we observed large red clods with dotted vessels, subtle white lines and pink structureless areas. In the previous reports of ALHE red clods were not observed. Our second case also presented with a focal area of red clods and subtle white lines and serpentine-looped vessels arranged on a pale pink-brown structureless area. Conclusions Pink lesions represent a challenge for dermatologists and dermoscopy has proven to be a valuable tool in improving the diagnosis of cutaneous neoplasms in comparison with examination with the naked eye. Although pink structureless areas, polymorphic vessels and white lines observed in our 2 cases can be observed in other pink nodular lesions, namely, amelanotic melanoma, Spitz nevus, and dermatofibroma, the presence of red clods is helpful in differentiating a vascular lesion from the aforementioned entities. Other vascular tumors such as angiosarcoma and Kaposi sarcoma are the major differential diagnoses for ALHE. In Kaposi sarcoma 4 Letter | Dermatol Pract Concept 2021;11(2):e2021003 the presence of large red clods is not expected as observed in our cases. Also, red clods are not reported in angiosarcoma. In conclusion, considering the typical location and clinical findings, ALHE should be kept in mind as a differential diag- nosis in the presence of dermoscopic red clods. References 1. Rodriguez-Lomba E, Avilés-Izquierdo JA, Molina-López I, Parra-Blanco V, Lázaro-Ochaita P, Suárez-Fernández R. Dermo- scopic features in 2 cases of angiolymphoid hyperplasia with eosin- ophilia. J Am Acad Dermatol. 2016; 75(1):e19-21. DOI: 10.1016/ j.jaad.2016.02.1145. PMID: 27317536. 2. Santosa C, Wardhana M, Saputra H. Angiolymphoid hyperplasia with eosinophilia with clinical pictures of keratoacanthoma: A rare case report. Clin Case Rep. 2019;7(1):189-192. DOI: 10.1002/ ccr3.1949. PMID: 30656039.