P6827Angiolymphoid hyperplasia with eosinophilia (ALHE): Histology, derma-toscopic features, and management

Andrea Hui, MD, State University of New York, Downstate, Brooklyn, NY, UnitedStates; Amor Khachemoune, MD, Veterans Affairs Medical Center, Brooklyn, NY,United States

Background: ALHE is a benign vascular proliferation of unknown pathogenesis withhistologically distinct endothelial cells and a mixed inflammatory infiltrate com-posed of mainly lymphocytes and eosinophils. It commonly occurs on the head andneck and has a tendency to recur after excision.

Case report: A 92-year-old white man presented to dermatology clinic with 2 tender,pink, shiny bumps on his retroauricular scalp that had been growing slowly forseveral months. The patient had a similar lesion in the same area, which had beenbiopsied 1 year earlier. Examination revealed 2 erythematous, shiny, mildly firm 0.5-cm and 0.4-cm papules overlying a subcutaneous plaque on the right retroauricularscalp.

Discussion: ALHE typically presents as multiple pink to reddish brown smooth-topped, dome-shaped papules or nodules on the head and neck, especially on thescalp and periauricular region. ALHE may appear clinically similar to a variety ofmalignant and benign vascular tumors. Lesions of ALHE appear as circumscribedproliferations of vessels with perivascular inflammation within the dermis andsubcutis. The inflammatory infiltrate consists of lymphocytes and eosinophils. Thevascular component of ALHE contains vessels of varying sizes, lined by plumphobnailed endothelial cells that may project into the lumen. The utility ofdermatoscopy in identifying vascular lesions has yet to be determined. To ourknowledge, we demonstrate the first report of the dermatoscopic features of ALHE.In our patient, the papules of ALHE demonstrate a diffuse reddish-brown erythemaand whitish globules with fine vessels on the surface of the papules. The typicallacunae (red, blue, black) of hemangiomatous lesions were not appreciated. Thereddish-brown erythema may represent the mixed inflammatory infiltrate overlyingthe vascular components of ALHE and the whitish globules may represent fibroticstroma. Although ALHE is a benign condition, lesions are often difficult to eliminateand recurrence is common. Surgical treatment is the standard treatment althoughrecurrence occurs in up to one third of cases.

Conclusion: ALHE is a benign vascular proliferation of unknown pathogenesis withhistologically distinct endothelial cells and a mixed inflammatory infiltrate com-posed of mainly lymphocytes and eosinophils. It commonly occurs on the head andneck and has a tendency to recur after excision.

AB44

cial support: None identified.

Commer

P5981Atypical presentation of hidradenitis suppurativa: A case report andreview of the literature

Ellecia Cook, DO, Nova Southeastern University Largo Medical Center, Largo, FL,United States; Brooke Walls, DO, Nova Southeastern University Largo MedicalCenter, Largo, FL, United States; David Esguerra, DO, Nova SoutheasternUniversity Largo Medical Center, Largo, FL, United States

Hidradenitis suppurativa is a chronic and progressive follicular occlusive inflamma-tory disease. This condition is often debilitating and typified by double comedones,deep nodules, and abscesses that coalesce to form draining sinus tracts resulting inhypertrophic scaring. Lesions most commonly affect the intertriginous hair-baringregions, such as the axillary or inguinal folds. Following is a case report of a 55-year-old woman who presented with several violaceous papules and nodules extendingfrom the midthoracic to upper lumbar region. Histologic examination was consis-tent with a follicular occlusion disorder. The presentation of hidradenitis suppu-rativa of the back is atypical and only rarely described. It is imperative to identifyatypical presentations of hidradenitis suppurativa in order to initiate promptappropriate treatment.

cial support: None identified.

Commer

J AM ACAD DERMATOL

P5952Autoimmune progesterone dermatitis associated with b-HCG diet drug

Karina Parr, MD, Scott and White Clinic and Texas A&M Health Science Center-College of Medicine, Temple, TX, United States; David Butler, MD, Scott andWhite Clinic and Texas A&M Health Science Center College of Medicine, Temple,TX, United States; Wesley Fletcher, MD, Scott and White Clinic and Texas A&MHealth Science Center College of Medicine, Temple, TX, United States

Autoimmune progesterone dermatitis is a rare disorder. It typically presents as acyclical cutaneous eruption that occurs during the luteal phase of the menstrualcycle when serum progesterone levels are high. Morphology of the lesions isvariable and includes erythema multiforme, urticaria, and eczematous patches.Triggers may be difficult to identify but it has occurred after hormone therapy orshortly after delivery. We report a case of a 44-year-old white woman who presentedwith an intensely pruritic eruption on her bilateral hands occurring intermittentlyfor a year. Physical examination revealed several 4- to12-mm nonblanchable darklyerythematous to violaceous macules and patches on the left volar wrist, right dorsallateral thumb, and left dorsal hand and digits. The patient used injectable b-HCG forweight loss a few months before the initial eruption. Since the first episode,eruptions have occurred in the same sites, appearing to be cyclical and to coincidewith her menstrual cycles. Symptoms improved with oral and topical steroids inaddition to antihistamines. The patient was started on continuous suppressive oralcontraceptive therapy by her gynecologist, and no recurrences of the eruptionshave occurred since that time. To our knowledge, this is the first reported case ofautoimmune progesterone dermatitis occurring after b-HCG diet products, and thetiming of symptoms suggests a possible association.

cial support: None identified.

Commer

P6220Azathioprine hypersensitivity presenting as neutrophilic dermatosis anderythema nodosum

Nikoo Cheraghi, University of Missouri-Kansas School of Medicine, Kansas City,MO, United States; April Deng, MD, University of Massachusetts Medical School,Worcester, MA, United States; Jeffrey Mailhot, MD, University of MassachusettsMedical School, Worcester, MA, United States; Mariko Yasuda, MD, University ofMassachusetts Medical School, Worcester, MA, United States

We report a 58-year-old man with a history of Crohn’s disease who developedazathioprine hypersensitivity presenting as neutrophilic dermatosis and erythemanodosum. Six days after initiating azathioprine (AZA), the patient was admitted forfever, abdominal pain, and diarrhea with multiple nontender 3- to 4-mm pustules onhis face, chest, and back. He also had a solitary, tender erythematous 1-cm nodule onhis right leg. Thiopurine methyltransferase (TPMT) activity was on the low end ofnormal. Punch biopsy of a pustule was negative for pathogenic organisms. Punchbiopsy of the leg nodule revealed a neutrophilic and granulomatous septalpanniculitis consistent with erythema nodosum. AZA was discontinued and within6 days, both eruptions resolved without sequelae. Medication rechallenge was notattempted. AZA hypersensitivity is a serious yet still under recognized condition inthe dermatologic community. The cutaneous findings of AZA hypersensitivity aredose independent, occurring regardless of TPMT activity and corticosteroid use. Ittypically presents as a neutrophilic dermatosis, within 4 weeks of AZA initiation.Cutaneous biopsy in the early stages can lead to prompt diagnosis and cessation ofAZA before life threatening anaphylactoid reactions occur. Medication rechallenge iscontraindicated and could lead to systemic shock syndrome.

cial support: None identified.

Commer

APRIL 2013