Case25: 35 y.o. Female. Lesion on the ear. Haemangioma? Lymphoma? Psudolymphoma?

Spitz tumour?

CASE 25- RCCASE 25- RC

CASE 25 - RC

A.Haemangioma

B. Angiolymphoid hyperplasia with eosinophilia

C. Kaposi’s sarcoma

D.Fibroma

E.Scar

CASE 25 - RC

A.Haemangioma

B. Angiolymphoid hyperplasia Angiolymphoid hyperplasia with eosinophiliawith eosinophilia

C. Kaposi’s sarcoma

D.Fibroma

E.Scar

Past Medical HistoryPast Medical History

• Asthma

• Hayfever

• Allergy to cats and dogs

• Urticaria

Drug HistoryDrug History

• Loratidine

• Cetirizine

• Neoclarityn

• Levocetirizine

• Salbutamol inh

• Allergy to penicillin

Investigations

• FBC

–Eosinophils: 0.39

• IgE

–1667 (0-120)

• U&Es, LFTs, ESR

–normal

• MRI head–No arteriovenous malformation

ALHE• Aetiology

– Unknown– ?arteriovenous shunts

• Gender– Females > males

• Age– 30-50 y.o.

• Site– Head and neck

• Morphology– Dermal papules, nodules,

plaques– Subcutaneous nodules

Br J Derm 1969, 81:1-15, Br J Derm 1969, 81:804-816, J Am Acad Dermatol 1985, 12:781-796

Differential Diagnoses

• Inflammatory angiomatous nodules• Pyogenic granuloma• Histiocytoid hemangioma• Kaposi’s sarcoma• Pseudolymphoma (lymphoid hyperplasia)• Cutaneous lymphoma• Kimura disease

ALHEALHE Kimura’s Kimura’s diseasedisease

PresentationPresentation Superficial papules or Superficial papules or nodules +/or nodules +/or subcutaneous nodulessubcutaneous nodules

Large subcutaneous nodulesLarge subcutaneous nodules

LocalisationLocalisation Head and NeckHead and Neck Head and NeckHead and Neck

PopulationPopulation Third and fourth decadesThird and fourth decades

CaucasianCaucasian

Female > maleFemale > male

Younger ageYounger age

AsianAsian

MaleMale

Regional Lymph Regional Lymph nodesnodes

InfrequentInfrequent PossiblePossible

Skeletal Skeletal involvementinvolvement

NoNo PossiblePossible

Blood eosinophiliaBlood eosinophilia MildMild MarkedMarked

Elevated serum Elevated serum IgEIgE

InfrequentInfrequent FrequentFrequent

Origin of the Origin of the diseasedisease

? Vascular origin ? Vascular origin (endothelial cell)(endothelial cell)

Chronic inflammatory Chronic inflammatory processprocess

Adapted from: Head and Face Medicine 2006, 2:32

Kimura’s

Treatment of ALHE

• Surgical excision• Cryotherapy• Curettage and

Electrodessication• Laser (argon, carbon

dioxide, PDL, copper vapor)

• Radiotherapy

• Tacrolimus 0.1% ointment

• Intralesional corticosteroids

• Oral retinoids• Topical imiquimod• Photodynamic therapy• Intralesional bleomycin

Dermatol Surg 2005, 31:713-16, J Dermatolog Treat 2004, 15(5):328-330, Dermatol Surg 2004, 30: 1169-1173,

Dermatology 1998, 197: 189-191, J Am Acad Dermatol. Aug 2003;49 (2 Suppl Case Reports): S195-6,

Clin Exp Dermatol 2009, June 17: Epub…..ahead of print

Management in our patient

• ‘08: Nd:YAG laser

• ‘08, ‘09: Tacrolimus 0.1% ointment

• ‘09: electrodessication

• ’09: Surgical excision

• ’09: Topical Fluocinolone acetonide

• ’09: Intralesional triamcinolone (40mg/1ml)