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What are Flame Figures ?

Pathology of Well's Syndrome - 10 important facts

Dr Sampurna Roy MD





Flame figures in histologic sections are an important diagnostic feature but not diagnostic of Well's Syndrome.

The diagnosis of Wells' syndrome should be based on the typical clinical picture and the course of the disease with its recurrences and histopathology.

Flame figures represent a reaction pattern that can occur in many other conditions.  

According some authors the term "eosinophilic cellulitis" is ambiguous, since it has been used for both Wells' syndrome and any eosinophil infiltrate with flame figures.


10 Important Facts about Well's Syndrome:


1. In 1971,  George Wells first described Wells' syndrome as a 'recurrent granulomatous dermatitis with eosinophilia'. It was called "eosinophilic cellulitis" by Wells and Smith in 1979.

2.  Wells' syndrome, or eosinophilic cellulitis is an idiopathic, recurrent, inflammatory dermatosis which is characterized clinically by an acute dermatitis resembling cellulitis.  

3. Lesions are mostly localized on the limbs or trunk. There is sudden onset of itching and burning sensation. The affected patients usually present with violaceous plaques over a 2- to 3-day period. The plaques resolve  spontaneously without scarring over 2–8 weeks.  Although erythematous, edematous plaques are the most common presentation, nodules, bullae, or a papulonodular eruption may also occur.

4. Etiology and pathogenesis are unknown, but the disease has been found to be associated with hematologic disorders in many cases. Recurrences can often be related to infections, arthropod bites, drug administration, or surgery.

5. Histopathologic examination of the skin lesions reveals a dense dermal eosinophilic infiltrate, marked edema, characteristic "FLAME FIGURES". In some cases palisading microgranuloma may be present.  Vasculitis is never found.

6. The flame figures have been considered to be secondary to aggregates of expelled eosinophilic granules and disintergrating eosinophils, around collagen fibers in the dermis. These are also considered to be small poorly circumscribed foci of necrobiotic collagen.

7. These eosinophilic bodies are not pathognomonic for eosinophilic cellulitis and have been described in other inflammatory conditions, such as eczema, prurigo, herpes gestationis, scabies, and bullous pemphigoid.

8. The most important factor in pathogenesis of eosinophilic cellulitis appears to be activation of eosinophils as a result of some aberrant regulation of the inflammatory process in the skin leading to tissue destruction. 

9. Blood (and bone marrow) eosinophilia, although not consistently found, is an important finding.

10. The differential diagnosis of Wells' syndrome is broad and includes infections, such as bacterial cellulitis, Toxocara canis, erythema chronicum migrans, arthropod bites and hypereosinophilc syndrome, chronic idiopathic urticaria and Churg-Strauss syndrome. 

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Rodríguez-Lojo R, Almagro M, Piñeyro F, et al. Eosinophilic Panniculitis and Insect Bite-Like  Eruption in a Patient with Chronic Lymphocytic Leukaemia: A Spectrum of the Same Entity. Dermatology Research and Practice. 2010;2010:263827. doi:10.1155/2010/263827.


Wells' syndrome, insect bites, and eosinophils.

Wells' syndrome is a distinctive disease entity and not a histologic diagnosis.

The histopathogenesis of the flame figure in Wells' syndrome based on five cases.

Eosinophilic infiltration with flame figures. A distinctive tissue reaction seen in Wells' syndrome and other diseases.

Eosinophilic infiltration with flame figures. A distinctive tissue reaction seen in Wells' syndrome and other diseases.

Febrile "migrating" eosinophilic cellulitis with hepatosplenomegaly: adult toxocariasis - a case report.

Eosinophilic cellulitis (Wells' syndrome) caused by a temporary henna tattoo.




Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)






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