Poikilodermatous Plaque-Like Hemangioma or Reactive Epidermal Hyperplasia Versus Angiogenesis of the Rear: Single Condition or Distinct Entities?

To the Editor: Benign angioproliferations of the buttocks in elderly patients have been described under several names in the dermatologic literature, including Poikilodermatous Plaque-Like Hemangioma (PPLH),1 Senile Gluteal Dermatosis (SGD),2 Prurigiform Angiomatosis (PA),3 and, more recently, Reactive Epidermal Hyperplasia and Angiogenesis of the Rear (REAR).4 Despite independent descriptions, these conditions exhibit strikingly similar clinical and histopathologic features, suggesting they may represent a single entity described under different terms. We present a case and review the literature to address this ongoing terminological debate. An 80-year-old man presented to the dermatology clinic with a 2-year history of an asymptomatic lesion on the left buttock. He denied any preceding trauma, insect bite, or injury at the site. There was no history of similar lesions elsewhere. He also reported no systemic symptoms. His medical history was significant for long-standing arterial hypertension, dyslipidemia, and type 2 diabetes mellitus, all of which were being managed with stable medications. There were no recent changes in his treatment regimen. On physical examination, a well-demarcated, 3.0 × 2.5 cm atrophic, erythematous to violaceous plaque with irregular peripheral hyperpigmentation was observed on the left buttock (Fig. 1). The lesion was neither tender nor indurated on palpation. A punch biopsy revealed epidermal orthokeratotic hyperkeratosis and irregular acanthosis, with proliferation of small-caliber blood vessels (capillaries/postcapillaries venules CD31+ and occasional lymphatics D2-40+) in the superficial dermis, accompanied by a sparse perivascular mononuclear inflammatory infiltrate (Fig. 2).FIGURE 1.: Clinical image of a well-demarcated, atrophic, erythematous to violaceous plaque with irregular peripheral hyperpigmentation, measuring 3.0 × 2.5 cm, on the left buttock of an 80-year-old man.FIGURE 2.: Histopathologic images showing the epidermis with orthokeratotic hyperkeratosis and irregular acanthosis, proliferation of small-caliber vessels, and sparse perivascular mononuclear cell infiltrate in the dermis [hematoxylin–eosin, ×40 (A) and ×100 (B)]. Positive CD31 staining in capillaries/postcapillaries venules [immunohistochemistry, ×40 (C)]. Positive D2-40 staining in lymphatic vessels [immunohistochemistry, ×40 (D)].The clinical and histopathologic features of our case overlap with those reported under different designations in the literature, including PPLH, SGD, PA, and the more recently proposed term REAR. PPLH was first described in 2019 by Semkova et al1 in a series of 16 patients. It typically presents in men older than 50 years as solitary, indolent, erythematous-to-violaceous plaques with poikilodermatous features—namely, atrophy, telangiectasia, and mottled pigmentation—often on the buttocks or lower extremities. Histopathology reveals proliferation of small-caliber dermal vessels and variable reactive epidermal changes, such as hyperkeratosis or acanthosis.1,5,6 GSD was first reported by Yamamoto et al7 in 1979. It is characterized by unilateral or bilateral hyperkeratotic, lichenified plaques on the gluteal area, predominantly affecting elderly, thin men with prolonged sedentary habits. It is associated with friction, pressure, and the use of hard seating surfaces. This lesion is usually asymptomatic, with a minority of patients describing pruritus or discomfort. The histopathologic changes of SGD are typically mild and nonspecific. Histopathology reveals hyperkeratosis, psoriasiform epidermal hyperplasia, vascular proliferation in the upper dermis, and reactive lymphohistiocytic perivascular infiltrate.2,8 PA, first described by Ortins-Pina et al3 in 2020, is characterized by asymptomatic or mildly pruritic erythematous patches or plaques, most commonly on the buttocks and intergluteal fold in older men. Histopathology reveals acanthosis and hyperkeratosis resembling prurigo/lichen simplex chronicus overlying a prominent proliferation of dilated capillaries and postcapillary venules.3,9 To unify these last 2, the designation REAR was recently introduced, in 2022, by Liang et al,4 emphasizing the anatomic location, angiogenic changes, and accompanying epidermal hyperplasia. Recognizing the overlapping features of PPLH, SGD, PA, and REAR is essential to avoid misdiagnosis and unnecessary interventions. In fact, these benign entities share similar clinical settings—elderly patients, buttock location, indolent course, and no malignant potential—along with histopathologic patterns of epidermal hyperplasia and dermal angiogenesis. Therefore, a unified terminology would improve diagnostic clarity, reduce confusion with malignant conditions such as poikilodermatous mycosis fungoides, and prevent aggressive treatments. In addition, dermatologists should prioritize conservative management and patient reassurance, because no effective therapies or systemic associations have been documented.1–4 In conclusion, we report a case of a benign vascular plaque of the buttock in an elderly man, with features overlapping those described under multiple names in the literature. Our case adds to this growing body of evidence and raises an important question: should PPLH, SGD, PA, and REAR be regarded as separate diagnoses, or simply as different names for the same entity?