wells syndrome is a rare condition of unknown etiology and pathogenesis . in 1971 , george wells first described this syndrome as a recurrent granulomatous dermatitis with eosinophilia . the term  eosinophilic cellulitis  was introduced by wells and smith in 1979 . wells syndrome is characterized by clinical features of cellulitis and a histopathologic picture of eosinophilic infiltrate of the dermis along with the presence of  flame figures . the typical clinical presentation of the eosinophilic cellulitis is mildly pruritic , recurrent , cellulite like plaque , although several clinical presentations like urticarial , papulonodular , and vesicobullous lesions have been reported , depending upon the location of the infiltrate . wells syndrome is associated with a range of disorders like arthropod bite , myeloproliferative disease , colon cancer , reaction to thiomersal - containing vaccination , churg strauss syndrome , hypereosinophilic syndromes , dermographism , onchocerciasis , herpes - simplex infection , immunobullous disease , and drug reaction . while some authors consider wells syndrome to be a histological reaction pattern,[35 ] others consider it to be a distinctive disease entity . a 32-year - old female presented with an erythematous , edematous plaque on the flexor aspect of left forearm of 10 days duration , associated with a prodrome of malaise followed by itching and burning sensation at the site [ figure 1 ] . the lesion was small initially , but later on increased to size of about 5 cm  4 cm . the plaque was pink - red in color at onset that evolved into violaceous color over a period of 10 days and subsided within 3 weeks , leaving mild hyperpigmentation . the severity of the episodes varied each time  at some times , the patient would require antihistamines and oral steroids for relief . absolute eosinophil count was 440 cells / mm ( normal : 40440 cells / mm ) . random blood sugar , liver and renal function tests , urinalysis , chest x - ray , and antinuclear antibodies were normal . histopathologic examination from a biopsy taken from the plaque showed moderately dense superficial and deep perivascular and periappendageal infiltrate of eosinophils and lymphocytes [ figure 2 ] . several eosinophils were scattered in the interstitium of reticular dermis and around the deep vascular plexus [ figure 3 ] . based on the clinical presentation and the histopathology , a diagnosis of wells syndrome was made . the patient was given oral prednisolone 40 mg/ day in tapering dose over 4 weeks . clinical photograph showing erythematous and indurated plaque on the flexor aspect of left forearm below elbow ( encircled ) photomicrograph showing moderately dense superficial and deep perivascular and periappendageal infiltrate of eosinophils and lymphocytes ( arrows ) ( h and e , 100 ) photomicrograph showing eosinophils scattered in the interstitium of reticular dermis and around the deep vascular plexus ( arrow ) ( h and e , 400 ) wells syndrome is a rare , idiopathic dermatosis with recurrent , erythematous , urticarial plaques that become more indurated and subsequently heal with mild pigmentation . the course of the disease is mild despite occasional constitutional symptoms . although wells syndrome is usually sporadic , familial , neonatal , and childhood cases have been reported . there is wide polymorphism in the clinical and histological presentation of the disease , depending upon the nature and location of the infiltrate . the diagnosis of the wells syndrome is based on the clinical features and the course of the disease , especially its recurrences and the histopathologic features of eosinophilic infiltration of the dermis . histopathologically , a dermal infiltrate of histiocytes , eosinophils , and eosinophilic granules occurs between collagen bundles , which form the classic  flame figures . classical flame figures were not documented in the histopathology of our case as the patient presented in the resolving phase . flame figures are not unique to the wells syndrome and can be found in any disorder with a eosinophil - rich infiltrate such as insect bites , pemphigoid and churg  strauss syndrome . the flame figures may disappear after the acute stage with the granulomatous infiltrate becoming more obvious . peripheral t - cell immunophenotyping studies have shown an increased proportion of cd3 and cd4 t cells . these lymphocytes spontaneously release significant amounts of interleukin 5 ( il- 5 ) which is involved in the pathogenesis of blood and tissue eosinophilia . the eosinophils then degranulate in the dermis , causing edema and inflammation . with immunofluorescent stains , dapsone , interferon - alpha , cyclosporine , antihistamines , or minocycline have also proved effective . history and clinical presentation should prompt the clinician to consider the diagnosis of the wells syndrome , and histopathologic examination should be done for confirmation .
wells syndrome or eosinophilic cellulitis is characterized clinically by an acute dermatitis resembling cellulitis and histopathologically by dermal eosinophilic infiltration . 
 various morphological presentations have been described . 
 we report a 32-year - old female with recurrent , erythematous plaques on left forearm of 8 months duration , associated with mild itching that resolved leaving mild hyperpigmentation .