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Acral pseudolymphomatous angiokeratoma of children (APACHE): Dermoscopic features and successful treatment with CO2 laser

Dear Editor, Acral pseudolymphomatous angiokeratoma of children (APACHE) is clinically characterized by angiomatous papules that preferentially affect acral areas of children. Although initially considered to be a type of vascular malformation, it is now being classified as a distinct type of pseudo-lymphoma (Chedraoui et al., 2010).We herein present a case of APACHE in a 30-year-old woman, focusing on the dermoscopic and therapeutic features. A 30-year-old Caucasian woman, with a skin phototype II, presented to our Department with a 14-year-old history of multiple, reddish, papulonodular lesions, irregularly distributed on the toes of the right foot (Figure 1). Her personal medical history was negative. Dermoscopically the lesions showed a peripheral white halo, central pinkish-violet color, milky-red areas associated with irregular linear and hairpin vessels. The histology showed in the epidermis vacuoletype interface changes with a mild exocytosis (Figure 2a,b). In the dermis there was a dense and band-like mixed infiltrate mainly composed of lymphocytes, histiocytes, plasma cells, and a variable number of eosinophils (Figure 2c). A significant dermal vascular component, characterized by thick-walled blood vessels exhibiting swollen endothelial cells, was present. Immunohistochemical analysis showed positivity to CD79a and CD3, while CD34 was observed in many vessels in the lesion. According to the clinical and pathological features a final diagnosis of APACHE was made. The patient performed one session of CO2 laser UltraPulse (HaKidma St 6, Yokne'am Illit, Israel) at 200 mJ and 5 W, with a resolution of the cutaneous lesions. After a follow-up of 21 months there were no local recurrences (Figure 3). APACHE is a rare benign dermatosis, classified as a pseudolymphoma. To our knowledge only two dermoscopic cases have been described to date (Pinos León & Granizo Rubio, 2017; Tokuda et al., 2012)In the current case, we saw structureless areas, milky-red areas, and polymorph vessels (mainly irregular linear and hairpin vessels). Contrariwise to Pinos León et al. we did not see peripheral brownish areas and a clear rainbow pattern. Histologically the polymorph vessels corresponded to the dense dermal vascular proliferation, while the peripheral white halo corresponded to the surrounded hyperkeratosis, parakeratosis, and the introflexions of the epidermis. The main histological differential diagnoses were other angiomatous cutaneous proliferations, above all Kaposi sarcoma (Tokuda et al., 2012). However, in Kaposi sarcoma, there is not a so evident polymorphous vascular proliferation. Other important clinical and pathological differential diagnoses are: angiokeratoma circumscriptum, angylymphoid hyperplasia with eosinophilia, arthropod-bite reaction, eruptive pseudo-angiomatosis, eruptive pyogenic granulomas, lymphomatoid papulosis, reactive angioendotheliomas, and atypical vascular lesions (Pinos León & Granizo Rubio, 2017; Tokuda et al., 2012; Chinnadurai, Sathe, & Surawicz, 2016).The etiology of APACHE syndrome is still