Angiolymphoid hyperplasia with eosinophilia successfully treated with imiquimod

Sir, Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon, benign vascular proliferation that primarily affects middle‐aged women with particular predilection for the head and especially for the periauricular area. Clinically, it is characterized by solitary or multiple red‐brown cutaneous papules or nodules, which are often pruritic or painful with little propensity for spontaneous resolution.1 Numerous therapeutic approaches have been tried for ALHE including destructive techniques such as electrodesiccation and cryotherapy, surgery, radiotherapy, glucocorticoids (topical or intralesional), retinoids, sclerosing injections, pentoxifylline, pulse dye laser,2 argon laser, interferon‐α2a3 and cytotoxic agents. We report a patient with refractory ALHE who was successfully treated by topical application of imiquimod cream. A 37‐year‐old white woman was referred to the Department of Dermatology University Clinic of Navarra with an 8‐year history of red‐brown itchy and tender nodules located on her left ear and preauricular area. The lesion started insidiously with no tendency for spontaneous resolution. There were no regional lymphadenopathy or laboratory abnormalities, especially peripheral eosinophilia. At the time of our first examination, the patient had erythematous papulonodules, tan, dull red in colour, located around the tragus, with involvement of meatus acusticus externus (Fig. 1a). Magnetic resonance imaging showed no arteriovenous malformation. She had previously been treated with excision and with intralesional and topical glucocorticoids, which all provided temporary improvement but no lasting benefits. Histopathological examination confirmed a diagnosis of ALHE. The lesion was composed of small abnormal blood vessels lined by prominent cells with abundant cytoplasm or solid aggregates of epithelioid cells. This abnormal vascular proliferation was disposed around a small‐sized artery showing fibrotic change. Mitotic figures were not observed. Surrounding the abnormal vessels was a dense inflammatory infiltrate characterized by lymphocytes intermixed with abundant eosinophils (Fig. 2). The patient started treatment with 5% imiquimod cream five times a week. By the second week she complained of pain, marked erythema, and tenderness of the affected area, and treatment was withdrawn for 7 days. Erythema and scaling improved spontaneously despite continued treatment. After 16 weeks of topical imiquimod use, the patient had nearly complete clinical resolution of the disease. She has remained free of overt disease for 4 months (Fig. 1b).