Angiolymphoid hyperplasia with eosinophilia treated with imiquimod

Angiolymphoid hyperplasia with eosinophilia (ALHE), or epithelioid hemangioma, is an uncommon benign vascular proliferation that rarely affects children and only occasionally involves the upper extremities. We report a previously healthy 9-year-old girl with a 1-year history of pruritic, violaceous, firm nodules grouped on the left arm and forearm, refractory to topical corticosteroids. Histopathology showed dermal dilated capillary vessels lined by plump endothelial cells, with a dense lymphocytic infiltrate rich in eosinophils and no lymphoid follicles. Laboratory tests, including eosinophil count, immunoglobulin E, renal function, and urinalysis, were normal, and Bartonella spp. The studies were negative. The findings supported ALHE and excluded Kimura disease and bacillary angiomatosis. Given the multifocal involvement and the wish to avoid invasive treatment, topical imiquimod 5% was started once daily, leading to complete clinical resolution within 1 month and no recurrence after 2 years. This case highlights imiquimod as a useful non-invasive option in pediatric multifocal ALHE.