LETTER TO EDITOR
Year: 2020 • Volume: 3 • Issue: 1 • Page: 15-16

CHRYSALIS SIGN– A NEW DERMOSCOPICENTITY IN THE DIAGNOSIS OF ANGIOLYMPHOID HYPERPLASIA WITH EOSINOPHILIA

Aseem Sharma1, Rachita Dhurat1, Tejas Vishwanath1, Sandip Agrawal1, Deep Jarsania1, Richa Sharma1
1 Dept of Dermatology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai – 50

Corresponding Author:
Dr Rachita Dhurat
OPD 16, 2nd floor, New OPD building, Sion Hospital, Mumbai-400022
Email: rachitadhurat@yahoo.co.in

How to cite this article:
Sharma S, Dhurat S, Vishwanath T, Agarwal S, Jasrania D, Sharma R. Chrysalis sign– A new dermoscopicentity in the diagnosis of angiolymphoid hyperplasia with eosinophilia. JDA Indian Journal of Clinical Dermatology 2020;3:15-16

Sir,
Dermoscopy plays a very important role in differentiating this benign, vasoproliferative disorder from ominous diseases such as Kaposi’s sarcoma, Kimura’s disease and cutaneous metastases. Dermoscopic signs, reported herein, and in a sevencase- series by Padilla et al include linear vessels, red dots, red lacunae, ulceration over a pale red background, when ALHE is examined under polarizing dermoscopy. In our observation of three cases, we found another sign – the Chrysalis sign, which is an established sign in a few conditions, viz., basal cellcarcinoma, melanomas, dermatofibromas and scar tissue . But this has not been reported in conjunction with ALHE.

In our cases, the site of presentation varied from the centro-facial region, to the concha of the ear and scalp. (Figure-1) Ulceration, with or without frank hemorrhage wa snoted in two cases. All three cases showed a central, yellow structureless area with chrysalis-like, white streaks on a homogenous red background with few linear and dotted vessels. This chrysalides pattern is seen, particularly, as short, white orthogonal and parallel streaks, akin to the structural framework of the pupa, an intermediate stage between larval and adult life in a butterfly or a moth, and hence the nosological analogy. It is seen exclusively on polarized dermoscopy due to refringence from the hypertrophic or disoriented collagen in the dermis. (Figure-1)Fig 1

Figure 1 a,b,c,d,e: a. Multiple grouped skin coloured to erythematous papules to nodules over scalp in third case whichisdescribed by
polarizeddermoscopy of the lesions over the scalp; with contact plate; 50x magnification [Dinolite AMZ413ZT], b. Papulo-nodularlesion over
the ala of leftnostril, in the second case, c. Twoerythematous nodules over the right concha, in the first case, d. Polarizeddermoscopy of the right conchallesionshowing diagonal and orthogonal linesarrangedperpendicularly – Chrysalis-like structures, using immersion oil as a contact medium; 50x magnification [Dinolite AMZ413ZT], e. Polarizeddermoscopy of the lesion over the right nostril, with contact plate; 12x
magnification [Dinolite AMZ413ZT].

Figure 2 a,b,c : a. Multiple proliferating bloodvessels, with plump endothelial cells, with abundant extravasation of RBCs and few eosinophils in the dermis and haphazardly arranged collagen fibres ; 20x Hematoxylin-Eosin ,b. Haphazardly arranged collagen fibres and bundles were noted, in both vertical and horizontal orientations; 10x Masson trichome histochemical stain and on, c. Verhoeff-Van Gieson histochemical stain 10x.

All three cases underwent a skin biopsy to confirm the diagnosis. Hematoxylin and eosinstaining revealed multiple proliferating blood vessels with abundant extravasation of RBCs and a few eosinophils in the dermis. These changes were consistent with ALHE. Haphazardly arranged collagenfibers and bundles were noted, in both vertical and horizontal orientations, which was confirmed on staining with Verhoeff Van-Geison and Masson’s trichrome (Figure-2). This disorientation contributes to the Chrysalis-like pattern. We analyzed the dermoscopic pictures by Lomba et al and noticed features consistent with the Chrysalis sign, and we discussed the same with the principal author. This sign should be added to the dermoscopic constellation of ALHE, to further knowledge on this enigmaticentity.

References
1. Padilla-España L, Fernández-Morano T, del Boz J, Fúnez-Liébana R. Angiolymphoid Hyperplasia With Eosinophilia: Analysis of 7 Cases.
Actas Dermo-Sifiliográficas (English Ed. 2013;104:353-355.
2. Marghoob AA, Cowell L, Kopf AW, Scope A. Observation of Chrysalis Structures With Polarized Dermoscopy. Arch Dermatol. 2009;145(5):618.

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