Skin thickening on shoulder
A 59-year-old Hispanic man asked his doctor to take a look at his right shoulder, which had an area of thickened and swollen skin that had been there for about 2 years. He said the area was painful and he wondered if he might have been bitten by a spider. The patient had well-controlled hypertension and recurrent back pain.
What's your diagnosis?
The pathology from a 4-mm punch biopsy of the involved area revealed mycosis fungoides (MF), a type of cutaneous T-cell lymphoma (CTCL). CTCL is a malignant lymphoma of helper T-cells that usually remains confined to skin and lymph nodes. The most common initial presentation involves scaly patches or plaques with a persistent rash that is often pruritic and usually erythematous. Patches may evolve to generalized, infiltrated plaques or to ulcerated, exophytic tumors. Lesions typically develop on non-sun-exposed areas.
Treatment of CTCL should be provided by a dermatologist and/or hematologist/oncologist experienced with this condition. For disease localized to the skin, treatment may begin with emollients, antipruritics, and topical high-potency steroids. Topical retinoids and topical chemotherapy are treatment alternatives for localized disease and effective adjuvants in generalized disease. Psoralen-enhanced ultraviolet light type A (PUVA) and narrowband ultraviolet B light have proven effective in early MF. More advanced disease with erythroderma or lymph node involvement should be treated with systemic chemotherapy or photophoresis. This patient was sent to a dermatologist and oncologist for further evaluation and treatment.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Nayar A, Usatine R. Mycosis fungoides. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:745-749.
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