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rubbery&#44; compressible nodule of approximately 3&#8239;cm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Skin ultrasound with a high-frequency &#40;6&#8211;19&#8239;MHz&#41; linear probe &#40;Esaote MySix&#174;&#41; revealed a poorly defined dermal&#8211;hypodermal lesion&#46; Ultrasound in B mode showed tubular hypoechoic foci with mild posterior acoustic reinforcement and isolated hyperechoic structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Color Doppler mode revealed a moderate increase in intralesional uptake that corresponded to high flow and low resistance in spectral mode &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Histology showed proliferation of dilated vessels with disorganized distribution at the level of the middle and deep dermis&#44; as well as eccrine gland proliferation and foci of adipose tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Due to the size of the lesion and the possible consequences of excisional surgery&#44; it was decided&#44; in agreement with the patient&#44; not to remove the lesion and to adopt a wait-and-see approach&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">EAH is a sometimes congenital skin tumor that generally presents during the first years of life&#46; However&#44; adult onset&#44; as in the present case&#44; has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The etiology and pathogenesis of EAH are poorly understood&#46; It has been proposed that EAH is a consequence of failed interaction between the epithelial and mesenchymal components that leads to abnormal proliferation of vascular and adnexal structures&#46; It has also been postulated that onset in adulthood may be a consequence of repeated microtrauma&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Appearance of EAH in adulthood may also be due to an absence of symptoms during the first few years and a consequent delay in diagnosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">EAH usually manifests as a single brownish&#44; blue&#44; or reddish lesion&#46; Multiple lesions can develop&#44; usually in the distal areas of the extremities&#44; palms&#44; and soles&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Most cases are asymptomatic&#44; although some patients may experience hyperhidrosis and local pain caused by neural infiltration of the eccrine component&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to the findings of the clinical examination&#44; some recently described dermoscopic findings may be diagnostically useful&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We decided to perform skin ultrasound because it is a rapid&#44; noninvasive technique that allows visualization of the deep component of lesions&#44; and identification of vascular lesions using color Doppler mode&#46; In our patient&#44; ultrasound revealed a poorly delimited structure at the dermal&#8211;hypodermal level with poorly defined hypoechoic areas&#44; which may correspond to intralesional vascular areas&#46; Furthermore&#44; we observed small hyperechoic areas that may correspond to adipose tissue septa interspersed throughout the lesion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis of EAH is clinical&#44; although histopathologic confirmation is necessary&#46; We observed proliferation of eccrine glands&#44; unstructured angiomatous capillaries at the level of the dermis&#44; and variable amounts of adipose tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The differential diagnosis of EAH includes the following&#58; vascular malformations&#59; tufted angioma &#40;develops during the first 5 years of life and can be associated with hypertrichosis or hyperhidrosis&#41;&#59; smooth muscle hamartoma &#40;solitary plaques of childhood onset accompanied by hypertrichosis and hyperpigmentation&#41;&#59; and rubber bleb nevus &#40;blue&#44; nodular&#44; depressed lesions&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; eccrine nevus is the entity most difficult to differentiate from EAH&#46; Unlike EAH&#44; which is a mixed variant&#44; eccrine nevus consists exclusively of eccrine tissue&#46; Furthermore&#44; while associated hyperhidrosis occurs in almost all cases of eccrine nevus&#44; this clinical finding is observed in only one third of EAH cases&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Definitive treatment consists of surgical resection&#44; although given the benign nature of the tumor resection is not always necessary&#44; and is usually only considered in cases involving bothersome symptoms such as hyperhidrosis&#46; Other therapeutic alternatives &#40;eg intralesional sclerosing agents&#44; botulinum toxin&#44; or laser&#41; may be useful in certain patients&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The case presented here underscores the value of imaging the differential diagnosis of EAH&#46;</p></span></span>"
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Case and Research Letters
Adult-Onset Eccrine Angiomatous Hamartoma: A Case Report With Ultrasound Findings
Hamartoma angiomatoso ecrino en la edad adulta y sus hallazgos ecográficos
A. Vilas-Sueiroa,
Autor para correspondencia
avilassueiro@gmail.com

Corresponding author.
, A. López-Armestob, M.T. Mosquera-Martínezc, B. Monteagudoa
a Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, Spain
b Facultad de Enfermería y Podología, Campus de Ferrol, Universidad de A Coruña, Ferrol, A Coruña, Spain
c Servicio de Anatomía Patológica, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, Spain
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rubbery&#44; compressible nodule of approximately 3&#8239;cm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Skin ultrasound with a high-frequency &#40;6&#8211;19&#8239;MHz&#41; linear probe &#40;Esaote MySix&#174;&#41; revealed a poorly defined dermal&#8211;hypodermal lesion&#46; Ultrasound in B mode showed tubular hypoechoic foci with mild posterior acoustic reinforcement and isolated hyperechoic structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Color Doppler mode revealed a moderate increase in intralesional uptake that corresponded to high flow and low resistance in spectral mode &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Histology showed proliferation of dilated vessels with disorganized distribution at the level of the middle and deep dermis&#44; as well as eccrine gland proliferation and foci of adipose tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Due to the size of the lesion and the possible consequences of excisional surgery&#44; it was decided&#44; in agreement with the patient&#44; not to remove the lesion and to adopt a wait-and-see approach&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">EAH is a sometimes congenital skin tumor that generally presents during the first years of life&#46; However&#44; adult onset&#44; as in the present case&#44; has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The etiology and pathogenesis of EAH are poorly understood&#46; It has been proposed that EAH is a consequence of failed interaction between the epithelial and mesenchymal components that leads to abnormal proliferation of vascular and adnexal structures&#46; It has also been postulated that onset in adulthood may be a consequence of repeated microtrauma&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Appearance of EAH in adulthood may also be due to an absence of symptoms during the first few years and a consequent delay in diagnosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">EAH usually manifests as a single brownish&#44; blue&#44; or reddish lesion&#46; Multiple lesions can develop&#44; usually in the distal areas of the extremities&#44; palms&#44; and soles&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Most cases are asymptomatic&#44; although some patients may experience hyperhidrosis and local pain caused by neural infiltration of the eccrine component&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to the findings of the clinical examination&#44; some recently described dermoscopic findings may be diagnostically useful&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We decided to perform skin ultrasound because it is a rapid&#44; noninvasive technique that allows visualization of the deep component of lesions&#44; and identification of vascular lesions using color Doppler mode&#46; In our patient&#44; ultrasound revealed a poorly delimited structure at the dermal&#8211;hypodermal level with poorly defined hypoechoic areas&#44; which may correspond to intralesional vascular areas&#46; Furthermore&#44; we observed small hyperechoic areas that may correspond to adipose tissue septa interspersed throughout the lesion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis of EAH is clinical&#44; although histopathologic confirmation is necessary&#46; We observed proliferation of eccrine glands&#44; unstructured angiomatous capillaries at the level of the dermis&#44; and variable amounts of adipose tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The differential diagnosis of EAH includes the following&#58; vascular malformations&#59; tufted angioma &#40;develops during the first 5 years of life and can be associated with hypertrichosis or hyperhidrosis&#41;&#59; smooth muscle hamartoma &#40;solitary plaques of childhood onset accompanied by hypertrichosis and hyperpigmentation&#41;&#59; and rubber bleb nevus &#40;blue&#44; nodular&#44; depressed lesions&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; eccrine nevus is the entity most difficult to differentiate from EAH&#46; Unlike EAH&#44; which is a mixed variant&#44; eccrine nevus consists exclusively of eccrine tissue&#46; Furthermore&#44; while associated hyperhidrosis occurs in almost all cases of eccrine nevus&#44; this clinical finding is observed in only one third of EAH cases&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Definitive treatment consists of surgical resection&#44; although given the benign nature of the tumor resection is not always necessary&#44; and is usually only considered in cases involving bothersome symptoms such as hyperhidrosis&#46; Other therapeutic alternatives &#40;eg intralesional sclerosing agents&#44; botulinum toxin&#44; or laser&#41; may be useful in certain patients&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The case presented here underscores the value of imaging the differential diagnosis of EAH&#46;</p></span></span>"
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