Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2024;14(1):e2024005 1 A Rare Case of Angiolymphoid Hyperplasia With Eosinophilia: A Dermoscopic and Therapeutic Teaching Point Marco Adriano Chessa1,2, Lorenzo Maltoni2, Silvia Robuffo2, Francesco Savoia3, Bianca Maria Piraccini1,2, Iria Neri2 1 Dermatology Unit - IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy 2 Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy 3 IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Skin Cancer Unit, Meldola, Italy Citation: Chessa MA, Maltoni L, Robuffo S, Savoia F, Piraccini BM, Neri I. A Rare Case of Angiolymphoid Hyperplasia with Eosinophilia: A Dermoscopic and Therapeutic Teaching Point. Dermatol Pract Concept. 2024;14(1):e2024005. DOI: https://doi.org/10.5826/dpc.1401a5 Accepted: May 17, 2023; Published: January 2024 Copyright: ©2024 Chessa et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Lorenzo Maltoni, MD, Dermatology, Sant’Orsola-Malpighi Hospital, Bologna, Italy. E-mail: lorenzo.maltoni2@studio.unibo.it Case Presentation A 45-year-old Caucasian woman referred to us for a 2-year history of multiple, intensely itchy, red-purple papulonod- ular 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 struc- tureless area (Figure 1, B and C). A punch biopsy was performed, and the histological ex- amination revealed pathognomonic features leading to the diagnosis of angio-lymphoid hyperplasia with eosinophilia (ALHE) (Figure 1D). Several treatments with a combination of CO2 and dye laser were performed leading to debulking of the lesions and the treatment of the vascular component. Our treatment pro- tocol 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/cm2. 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/cm2. For the Dye laser, we used a 7 mm spot size, 1.5 ms pulse duration, and fluence of 12.0 J/cm2. 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 in- structed to apply the ointment to the treated area for 7 days. The patient was evaluated every 3 weeks with import- ant improvement of her symptoms and minimal scarring (Figure 1E). 2 Image Letter | Dermatol Pract Concept. 2024;14(1):e2024005 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 pat- tern 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 diag- nosis 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 recur- rences may occur and multiple treatments and follow up are mandatory [2]. References 1. Akay BN, Fatih Atak M, Farabi B. Dermoscopic Features of Two Cases of Angiolymphoid Hyperplasia with Eosino- philia and Review of the Literature. Dermatol Pract Concept. 2021;11(2):e2021003. DOI: 10.5826/dpc.1102a03. PMID: 33747617. PMCID: PMC7943206. 2. Zou A, Hu M, Niu B. Comparison between Kimura's disease and angiolymphoid hyperplasia with eosinophilia: case reports and literature review. J Int Med Res. 2021;49(9):3000605211040976. DOI: 10.1177/03000605211040976. PMID: 34525882. PMCID: PMC8451002. Figure 1. (A) Multiple red-purple papulonodular skin lesions on the occipital area of the scalp; (B) Central amorphous pink-whitish structure with dotted and peripheral linear unfocused vessels; (C) Red clods in the central part on pink-whitish background; (D) Histology revealed a proliferation of blood vessels, lymphoid tissue and a high number of eosinophils within the lesion (H&E magnification X20); (E) Clinical picture of the improvement after ablative treatment with the combination of CO2 and dye laser.