From suspicion to resolution: Sclerotherapy in a case of facial pseudolymphoma

INTRODUCTION

Cutaneous lymphoid hyperplasia (CLH), also known as pseudolymphoma, is a benign lymphoproliferative condition that is often misinterpreted as a malignancy due to its variable clinical appearance. It may manifest as nodules, plaques, or papules and commonly mimics cutaneous lymphomas, necessitating careful evaluation and differentiation.¹ The pathogenesis involves a reactive lymphoproliferative response triggered by exogenous antigens such as insect bites, infections, trauma, tattoos, or drugs, leading to the accumulation of benign lymphoid infiltrates in the dermis. While some cases are drug-induced and resolve upon withdrawal of the offending agent, many remain idiopathic.^1,2

CLH typically affects individuals in the third to fifth decade, with a slight male predominance. Despite its benign nature, diagnostic uncertainty and cosmetic implications often pose therapeutic challenges.¹

Various treatment modalities have been described in the literature, including topical and intralesional corticosteroids, excision, cryotherapy, phototherapy, and immunomodulators. However, there is no standardized treatment.^2,3 Sclerotherapy, commonly used for vascular lesions, has been sporadically mentioned in the context of CLH, but data remain scarce.⁴ Herein, we report a case of CLH managed effectively with intralesional polidocanol foam, a novel, minimally invasive modality.

CASE REPORT

A man in his 30s presented with a gradually enlarging, firm, erythematous nodule on the left malar cheek over 2–3 months. He denied any history of trauma, insect bites, discharge, or systemic symptoms. The persistence of the lesion despite the absence of triggering factors such as recent trauma, new medications, or local infection raised suspicion of a deeper pathology. He was a known diabetic, well-controlled on metformin. The patient had no significant family history of hematologic or cutaneous malignancies and no prior history of similar lesions.

Examination revealed a solitary, non-tender, dome-shaped nodule measuring approximately 1.5 cm. On palpation, the lesion was found to be firm, immobile, and fixed to the underlying dermis but not to deeper structures. There was no ulceration, discharge, or telangiectasia. The overlying skin was intact and showed no signs of excoriation or secondary changes [Figure 1]. No regional lymphadenopathy or other skin lesions were noted . The review of systems was unremarkable, and routine laboratory tests were within normal limits, except for mild hyperglycemia. Histopathological examination of the lesion revealed a dense lymphocytic infiltrate in the dermis, consistent with CLH [Figure 2]. The histopathological findings, combined with the clinical presentation of a firm, solitary, non-ulcerated lesion without systemic signs, supported a diagnosis of CLH. The choice of sclerotherapy was made after carefully weighing therapeutic options, particularly considering the cosmetic sensitivity of the facial region and the requirement of a minimally invasive approach.

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Figure 1:

A solitary, dome-shaped, erythematous nodule over the left malar cheek. The lesion appears firm and well circumscribed, with intact overlying skin and no signs of ulceration, telangiectasia, or secondary changes.

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Figure 2:

Histopathological examination of the lesion revealed (a) low-power view (hematoxylin and eosin, ×4) showing diffuse lymphoid infiltration in the dermis (red arrow). (b) Intermediate magnification (H&E, ×10) highlighting band-like lymphocytic architecture (blue arrow). (c) High-power view (H&E, ×40) demonstrating a polymorphous infiltrate of small lymphocytes and plasma cells without atypia (yellow arrow).

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Conventional treatments such as surgical excision carry the risk of scarring and disfigurement, especially on exposed areas like the cheek. The patient opted against surgical excision due to cosmetic concerns. Intralesional corticosteroids are another option, but can lead to dermal atrophy or pigmentary changes.

Two sessions of intralesional sclerotherapy with polidocanol were administered 15 days apart. The patient was administered intralesional foam sclerotherapy with 0.25% polidocanol foam, prepared using the Jessari double-syringe method. In this method, equal volumes (1:1) of liquid sclerosant and air were drawn and agitated to generate a uniform foam. A total volume of 0.2 mL of foam was injected intralesionally at each session.

This method allowed uniform distribution of the sclerosant within the lesion, ensuring adequate endothelial disruption while minimizing the risk of tissue necrosis. No adjunctive treatments were administered.

During follow-up visits at 1, 2, and 3 months, the lesion demonstrated progressive flattening, reduction in erythema, and softening in texture [Figure 3]. No signs of relapse or post-inflammatory changes, such as pigmentation or scarring, were observed over the next 3 months. The rapid response to treatment further validated the clinical diagnosis.

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Figure 3:

Post-treatment clinical image at 3-month follow-up showing significant regression of the lesion with flattening, decreased erythema, and normalization of skin texture, without any scarring or pigmentary changes.

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The patient reported high satisfaction with the outcome and cosmetic appearance and experienced no procedural discomfort or systemic side effects. Given the favorable response, no further intervention was necessary. The case underscores the potential of sclerotherapy as a treatment for CLH.

DISCUSSION

CLH, also termed pseudolymphoma, presents a unique clinical conundrum due to its deceptive resemblance to primary cutaneous lymphomas. Although histologically benign, its clinical mimicry of malignancy mandates a careful exclusion of cutaneous lymphomas through a combination of clinical judgment, histopathological evaluation, and response to therapy.^1,2,5 In the present case, histopathology demonstrated a dermal lymphocytic infiltrate, confirming the diagnosis of CLH.

The etiopathogenesis of CLH involves a reactive lymphoid proliferation secondary to various antigenic stimuli, including arthropod bites, tattoos, trauma, infections, and drugs.^1,2,6 Notably, many cases remain idiopathic, as was true in our patient. The facial localization, solitary nature, and indolent course of the lesion, with no prior drug exposure or trauma, further strengthened the diagnosis of idiopathic pseudolymphoma.^5,7

Therapeutic approaches to CLH are varied and often dictated by lesion location, size, patient preference, and diagnostic uncertainty. Conventional treatments include intralesional or topical corticosteroids, surgical excision, cryotherapy, and systemic immunomodulators.^1,5,8 Excision, while curative, may be cosmetically unacceptable in exposed areas such as the face. Likewise, intralesional corticosteroids, though frequently used, can be associated with dermal atrophy, hypopigmentation, or telangiectasias.^1,5

In this context, our case introduces a novel therapeutic strategy – the use of sclerotherapy with polidocanol foam, a modality traditionally reserved for vascular anomalies such as hemangiomas, varicose veins, and venous malformations.⁴ To the best of our knowledge, there are no prior published reports of intralesional sclerotherapy in facial CLH, making this a unique contribution to dermatologic literature.

The therapeutic rationale lies in the sclerosant’s ability to cause endothelial disruption, local thrombosis, and fibrosis, leading to lesion involution. In lymphoid proliferations, sclerotherapy may additionally induce stromal remodeling, immune modulation, or even vascular occlusion within the reactive infiltrate, contributing to regression.⁴ The Jessari double-syringe technique allowed for uniform foam generation, enhancing lesion contact and minimizing local necrosis or systemic absorption.

The response in our patient was rapid and sustained, with complete flattening and normalization of the skin surface within 4 weeks. No adverse effects or pigmentary alterations were observed at 3-month follow-up, affirming both the safety and cosmetic advantage of the method.

The role of sclerotherapy in CLH, while promising, remains underexplored. This case contributes to the expanding range of therapeutic options for CLH. Given its minimally invasive nature, ease of administration, affordability, and esthetic advantage, it may represent a valuable alternative for patients who are unwilling or unfit for surgery, or where corticosteroid side effects are a concern.

However, vigilance is necessary, as rare cases of transformation into cutaneous lymphoma have been documented.^2,5,9 Regular clinical follow-up is essential in all patients diagnosed with CLH, even when managed conservatively.

CONCLUSION

This case contributes to the growing recognition of sclerotherapy as a therapeutic innovation in dermatology, extending its applications beyond conventional vascular uses. In the context of CLH, especially in cosmetically sensitive or surgically challenging sites, it offers a safe, effective, and cosmetically favorable option. In the absence of prior literature documenting this approach for facial pseudolymphoma, our report adds valuable clinical insight and opens avenues for future exploration. As dermatologic practice moves toward individualized, minimally invasive care, such modalities merit greater exploration. Future studies are warranted to validate its efficacy across larger cohorts and define indications, dosing protocols, and long-term outcomes.