Topical corticosteroids for mycosis fungoides. Experience in 79 patients

Management of refractory early-stage cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) is a heterogeneous group of non-Hodgkin's lymphomas that manifest primarily in the skin. Mycosis fungoides is recognized as the most common type of CTCL. Patients with early-stage CTCL usually have a benign and chronic disease course. However, although there is a wide array of therapeutic options for early-stage CTCL, not all patients respond to these individual therapies, resulting in refractory cutaneous disease over time. Refractory early-stage CTCL poses an important therapeutic challenge, as one of the principal treatment goals is to keep the disease confined to the skin, thereby preventing disease progression. Much of the focus of current research has been on the evaluation of already available skin-directed therapies and biologic response modifiers and combination regimens thereof, such as the combination of psoralen and UVA (PUVA) with interferon-alpha or retinoids. Recent novel developments include oral bexarotene, a retinoid X receptor-selective retinoid that has activity in all stages of CTCL and has been shown to be effective in patients with refractory early-stage disease as well as advanced-stage disease. Likewise, the topical gel formulation of bexarotene has proved to be an important therapeutic option in patients with refractory or relapsed lesions. Oral bexarotene and topical bexarotene have been approved by the US FDA for the treatment of refractory CTCL. Systemic chemotherapy is typically reserved for advanced-stage CTCL and is usually not recommended for early-stage, skin-limited disease. However, recent exploratory studies indicate that low-dose methotrexate may represent an overall well tolerated therapy in a subset of patients with refractory early-stage CTCL, as may pegylated liposomal doxorubicin, which is currently being investigated in this specific clinical setting. Another recently FDA-approved therapy is the interleukin-2 fusion toxin denileukin diftitox, which is now well established to play a role in the treatment of refractory CTCL, including early-stage extensive plaque disease. The value of other agents, such as topical tazarotene, topical methotrexate, and topical imiquimod, and of novel immunomodulatory approaches including monoclonal antibodies, still needs to be assessed for refractory early-stage CTCL.

Emerging drugs in cutaneous T-cell lymphomas

Cutaneous T-cell lymphomas are a heterogeneous group of rare lympho-proliferative disorders. In most cases, they are characterised by the accumulation of clonal CD4+ lymphocytes in the skin. Extracutaneous involvement is present in late stages only. Unfortunately, only few drugs are registered for these disfiguring diseases. Skin-directed therapies using topical formulations are the preferred first-line modalities for cutaneous lesions in early stages. In this field there are interesting developments using topical retinoids and gene therapy products, such as adeno-IFN-gamma. Systemic treatment uses biologicals, such as fusion molecules, monoclonal antibodies and immune response modifiers (IFNs, retinoids), and well-tolerated antiproliferative drugs, such as histone deacetylase inhibitors or liposomal doxorubicin.

Purine Analogues in Advanced T-Cell Lymphoid Malignancies

T-cell lymphomas account for 10% to 15% of all lymphoid malignancies. In advanced stages of T-cell lymphoma, single or multiagent chemotherapy and bioimmunotherapeutic agents have been used. Purine analogues have demonstrated activity in both refractory cutaneous T-cell lymphoma and peripheral T-cell lymphoma with response rates ranging from 20% to 70%. Response rates have been higher with pentostatin (60%) than with the other compounds in this class. The potential limitation to this therapy is the prolonged immunosuppression, which increases the risk of opportunistic injections in patients who are already at heightened risk for infections. Patients should be monitored closely with CD4 counts and surveillance for opportunistic infections. Future studies of purine analogues should evaluate patients who are less heavily pretreated and combination therapy with other agents such as alemtuzumab should be investigated in order to prolong the duration of disease remission.

EORTC consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome

Several reviews and guidelines on the management of mycosis fungoides and Sézary syndrome (MF/SS) have been published; however, treatment strategies for patients with MF/SS vary from institution to institution and no European consensus has yet been established. There are few phase III trials to support treatment decisions for MF/SS and treatment is often determined by institutional experience. In order to summarise the available evidence and review 'best practices' from each national group, the European Organisation for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Task Force met in September 2004 to establish European guidelines for the treatment of MF/SS. This article reviews the treatment regimens selected for inclusion in the guidelines and summarises the clinical data for treatments appropriate for each stage of MF/SS. Guideline recommendations are presented according to the quality of supporting data, as defined by the Oxford Centre for Evidence-Based Medicine. Skin-directed therapies are the most appropriate option for early-stage MF/SS and most patients can look forward to a normal life expectancy. Patients with advanced disease should be encouraged to participate in clinical trials and maintenance of quality of life should be paramount.

Combination Treatment Modalities in Cutaneous T-Cell Lymphoma (CTCL)

A wide variety of cutaneous T-cell lymphoma therapies are now used in clinical practice. Treatment options include phototherapy, radiation, topical therapy, systemic mono-chemotherapy, combination chemotherapy, and combined modalities. Many patients fail or develop resistance to monotherapy, resulting in a need for combined treatment modalities to improve therapeutic results in terms of quality of life and duration of response. Recently, bexarotene, a selective antagonist of the retinoid X receptor, has been approved in the treatment of patients with cutaneous T-cell lymphoma. Bexarotene offers new opportunities for combination treatment strategies because of its novel and unique mechanism of action. In this article we review the rationale and examine key published evidence on combining these new treatment modalities.

Primary Cutaneous T-Cell Lymphomas

Primary cutaneous T-cell lymphomas (CTCLs) encompass a clinically and biologically heterogeneous group of non-Hodgkin lymphomas (NHLs) defined by clonal proliferation of skin-homing malignant T lymphocytes and natural killer cells. They account for up to 75% to 80% of all cutaneous lymphomas. The current WHO-EORTC classification of cutaneous lymphomas with primary cutaneous manifestations lists 13 entities. The most common subtypes—mycosis fungoides, Sézary syndrome, primary cutaneous anaplastic large cell lymphoma, and lymphomatoid papulosis—which represent approximately 95% of CTCLs, will be discussed in the following review. Each entity has unique biological characteristics and clinical course. Topical and/or systemic therapies are employed based on the stage of the disease and the tempo of progression.

What's new in the management of cutaneous T-cell lymphoma?

The aetiology and clinical management of primary cutaneous T-cell lymphoma (CTCL) and specifically of mycosis fungoides and Sezary syndrome are poorly defined. Interesting new insights into CTCL disease biology as well as a number of emerging of novel therapeutic interventions make this an increasingly interesting area for dermatologists and oncologists involved in the treatment of CTCL. This review article covers much of this new information including new drugs, such as denileukin diftitox (Ontak) a targeted cytotoxic biological agent, Bexarotene an RXR selective retinoid, anti-CD4 monoclonal antibodies (mAb), new cytotoxics agents and vaccines.

Cutaneous T-cell lymphoma treatment using bexarotene and PUVA: A case series

BACKGROUND

Mycosis fungoides, the most common form of cutaneous T-cell lymphoma, often presents as chronic eczematous or psoriasiform patches and plaques that can be resistant to a variety of single-agent treatment modalities, necessitating combination therapy.

OBJECTIVE

To evaluate the efficacy of combination therapy with bexarotene and psoralen plus ultraviolet A (PUVA) in treating patients with cutaneous T-cell lymphoma (CTCL) that recurred following monotherapy with multiple agents, including electron-beam irradiation, interferon, PUVA, and topical steroids. This was done by retrospective chart review.

METHODS

Retrospective chart review analysis of eight patients with CTCL ranging from stage Ia to IIb who failed multiple single-agent treatment regimens treated with low-dose oral bexarotene and PUVA combination therapy.

RESULTS

We noted an initial response in all eight patients and complete remission in five of the patients treated, with pruritus being the most common adverse event.

CONCLUSION

In view of its good safety profile, combination therapy with bexarotene and PUVA may be considered for patients with treatment resistant CTCL refractory to monotherapy.

Low-dose methotrexate to treat mycosis fungoides: a retrospective study in 69 patients

BACKGROUND

Although low-dose methotrexate has been used to treat mycosis fungoides for many years, documentation is very limited.

OBJECTIVE

Our purpose was to review our experience with methotrexate in the treatment of 69 patients with patch/plaque and tumor stage mycosis fungoides observed for up to 201 months.

METHODS

This was a retrospective study. Data are presented in terms of response rates and time to treatment failure.

RESULTS

The greatest number of patients (60) had patch/plaque stage T2 disease (>/=10% skin involved). Of these, 7 (12%) achieved complete remission and 13 (22%) achieved partial remission for a total response rate of 20 of 60 (33%). The median time to treatment failure was 15 months. Only 1 of 7 patients with tumor stage disease responded. Side effects caused treatment failure in 6 (9%) of the total cohort of 69 patients.

CONCLUSION

Low-dose methotrexate may be of value in the treatment of a subset of patients with patch/plaque mycosis fungoides resistant to other therapies.

Management with topical nitrogen mustard in mycosis fungoides

Topical nitrogen mustard (mechlorethamine, NM) has been used as primary therapy for management of patients with mycosis fungoides (MF) since the 1950s. Many investigators have demonstrated the efficacy of topical NM in patch and/or plaque disease of MF. Updated results from Stanford also confirm the clinical efficacy. The complete response (CR) rates reported are 76-80% for patients with limited patch/plaque (stage IA), and 35-68% for those with generalized patch/plaque (stage IB) disease. Topical NM can be used as an aqueous (water) or ointment-based preparation. The efficacy results are similar in patients who were treated with aqueous versus ointment preparations. Maintenance regimens used are variable, but there is no data to suggest that a longer maintenance duration results in greater potential for long-term remission. Most patients who achieve initial CR with topical NM tend to require NM-only for disease management. Topical NM is equally effective when used as salvage therapy with disease relapse. The most common toxicity of topical NM therapy is contact irritant or allergic reaction. The potential for allergic reaction is significantly reduced (< 10%) when NM is used as an ointment preparation. The potential for secondary skin cancer development is increased in patients who have used multiple sequential topical skin-damaging therapies or NM in the genital skin, but not in patients who have used NM as monotherapy (avoiding genital skin application). Topical NM is used safely in pediatric patients and there is no evidence of any clinically significant systemic absorption of topically applied NM.

Current management strategies for cutaneous T-cell lymphoma

Cutaneous T-Cell Lymphoma is a group of lymphomas characterized by a malignant proliferation of skin homing T cells. Prognosis is generally good and treatment is based on the stage of the disease with the goal of inducing remission. Patients with disease limited to the skin in the form of patches and plaques respond best to "skin directed therapy" with topical agents including corticosteroids, nitrogen mustard, carmustine, bexarotene gel, as well as phototherapy with ultraviolet B light, PUVA, or photodynamic therapy. Tazarotene and imiquimod show potential in the treatment of early CTCL. Patients with disease resistant to treatment or with advanced disease require more aggressive therapy in the form of total skin electron beam radiation, biologic response modifiers including interferon alpha, bexarotene, denileukin diftitox, extracorporeal photochemotherapy or combination therapy. The use of chemotherapy is used primarily for palliation. Allogeneic hematopoetic stem cell transplantation may represent a successful treatment for treatment resistant disease.

Management of the primary cutaneous lymphomas

Cutaneous lymphomas are rare and, although some are a manifestation of systemic lymphoma, the majority arise primarily from the skin. These primary cutaneous lymphomas comprise both T- and B-cell subtypes and represent a wide spectrum of disorders, which at times can be difficult to diagnose and classify. Classical therapeutic strategies include topical corticosteroids, phototherapy, radiotherapy, retinoids, extracorporeal photopheresis, topical chemotherapy, systemic chemotherapy and biological response modifiers. Newer therapies include the synthetic retinoid bexarotene, the immunotoxin conjugate denileukin diftitox, interleukin-12 and monoclonal antibodies such as alemtuzumab and rituximab.

Treatment of patch-stage mycosis fungoides with topical corticosteroids

Experience at the University of California, San Francisco (UCSF), in the management of patch-stage mycosis fungoides (MF) with topical, predominantly high-potency, corticosteroids is reviewed. The technique of applications is discussed in detail. Approximately 200 patients have been treated. The results are very favorable. The response rate is over 90%. Side-effects are minor. Topical clobetasol is the first-line treatment for early stage MF at UCSF.

Prognosis, clinical outcomes and quality of life issues in cutaneous T-cell lymphoma

Although the need for a specific QOL index for MF/SS has been recognized, little work has been done in this area. QOL instruments should address general health concepts, as well as specific issues that are relevant to patients who have MF/SS; a combination of two instruments may be appropriate. Confirming the validity, reliability, and responsiveness to change of a combination of QOL instruments, such as SKINDEX-29 and FACT-G, in patients who have MF/SS will be relevant. For patients who have MF/SS, focusing our efforts on improving the disease and their QOL should translate into improvements that are meaningful to them. Thus, our goal should be to incorporate the findings of QOL research into practice and use the results to guide our practices, as they relate to therapy. Some important considerations are: We must be explicit about what will be done with the information that is obtained about an individual's QOL. We should consider what additional knowledge QOL measures provide that we could not otherwise have. We should be ready for unexpected results, as exemplified by instances where aggressive therapy could result in improved QOL. Although challenges exist in moving forward QOL research in CTCL, the words of wisdom of Tannock bring the concept of QOL into perspective: "When cure remains elusive, it is time to start treating the patient, not just the tumor." A final consideration is that we should not forget the dimension of spirituality, which is especially relevant to patients who have advanced MF/SS. Spirituality is characterized by the capacity to seek purpose and meaning, to have faith, to love, to forgive, and to see beyond current circumstances. Spirituality enables a person to rise above suffering. Unfortunately, research on spirituality is scarce, in part, because of the difficulty in assessing spiritual suffering. Nevertheless, physicians who are caring for patients who have advanced MF/SS should acknowledge the spiritual dimension as an integral component of the dying process.

[Standard and experimental therapy of cutaneous T-cell lymphoma]

Cutaneous T-cell lymphoma represent a heterogeneous group of diseases characterized by skin invasion of monoclonal T-lymphocytes. These cutaneous T-cell lymphomas are divided into 3 groups based on clinical, histological and immunohistological characteristics: Indolent with a survival time of over 10 years, aggressive with a survival time less than 10 years and provisional (EORTC classification). Standard treatments such as PUVA, total skin electron beam, methotrexate, polychemotherapy regimens, retinoids and photopheresis have been used for years. Bexarotene is a newly registered drug. To achieve better response rates, several new drugs are being evaluated in clinical trails, including imiquimod, denileukon-diftitox, liposomal doxorubicin, adeno-interferon-gamma and various combination approaches.

Lymphoma of the skin

This chapter describes the various ways in which the non-Hodgkin's lymphomas can involve the skin, how these diseases should be assessed, standard treatments available in 2002, and new directions in research. The goal of the session is to succinctly review recent developments in lymphoma classification and treatment as they apply to the unique aspects of lymphoma when manifest in the skin. In Section I, Dr. Eric Hsi reviews the special characteristics of the lymphomas seen when they proliferate in the skin and the application of the new World Health Organization classification system to the cutaneous lymphomas, emphasizing the unique challenges of recognizing and correctly classifying these diseases. He summarizes the evidence in favor of including the skin lymphomas in the overall lymphoma classification scheme and concludes with a practical description of the specific skin lymphoma entities. In Section II, Dr. Joseph Connors describes the current optimal treatment of the B-cell lymphomas when they present in or metastasize to the skin. Building on the classification scheme described by Dr. Hsi, Dr. Connors outlines a treatment approach based on current understanding of pathophysiology of these diseases and application of each of the effective modalities available for cutaneous lymphoma including radiation, chemotherapy, and immunotherapy. In Section III, Dr. Francine Foss concludes the session with a discussion of the different T-cell lymphomas that start in or spread to the skin concentrating on mycosis fungoides, cutaneous anaplastic large cell lymphoma and peripheral T-cell lymphoma. She includes comments on the newer anti-T-cell chemo- and immuno-therapeutics focusing on agents and techniques specific for cutaneous T-cell lymphomas.

Treatment of childhood mycosis fungoides with topical PUVA

Mycosis fungoides is the most common type of cutaneous T-cell lymphoma, which is usually observed in mid to late adulthood. We report 5 cases of mycosis fungoides in children, all presenting as patch- and plaque-stage disease most commonly involving the buttocks. Histologic examination showed in every case the typical features of mycosis fungoides. In 4 of the 5 cases, the infiltrating lymphocytes were characterized by the T-cell phenotype CD3(+), CD4(+), CD8(+); and in 3 cases, a monoclonal rearrangement of the T-cell receptor gamma (TCR-gamma) gene was found. Three children received topical PUVA treatment, and the other two were treated with mid-potency topical corticosteroids, resulting in complete clinical remission. A management approach to mycosis fungoides with topical PUVA may be appropriate for children.

Total skin electron radiation in the management of mycosis fungoides: Consensus of the European Organization for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Project Group

Radiotherapy has been successfully implemented in the treatment of mycosis fungoides (MF) for almost a century. With the development of the modern linear accelerator, it has become possible to treat extended areas of the skin with accelerated electrons. Total skin electron beam radiation (TSEB) has been in use for several decades, and a number of technical modifications have been made with the goals of optimizing dose distribution and improving clinical outcome. Emerging evidence from recent studies suggests an association between TSEB techniques and efficacy in the treatment of MF. Based on this evidence, the European Organization for Research and Treatment of Cancer Cutaneous Lymphoma Project Group, in association with experts from radiotherapy centers in North America, has reached a consensus on acceptable methods and clinical indications for TSEB in the treatment of MF. The aims of this report are to enhance accessibility of this highly efficacious treatment modality to patients with MF and to provide a point of reference for further clinical research.

Phase II trial of interferon-alpha-2a plus psolaren with ultraviolet light A in patients with cutaneous T-cell lymphoma

PURPOSE

To evaluate the efficacy and side effects of psolaren with ultraviolet light A (PUVA) and interferon-alpha-2a (IFN-alpha-2a) in patients with mycosis fungoides (MF) and Sézary syndrome (SS).

PATIENTS AND METHODS

From May 1993 to January 1999, 63 symptomatic patients with all stages of MF and SS were treated in a prospective Phase II trial with systemic escalating doses of IFN-alpha-2a combined with PUVA for 1 year, followed by indefinite PUVA maintenance in complete responding patients.

RESULTS

Sixty-three patients were enrolled (Stage IA, n = 6; IB, n = 37; IIA, n = 3; IIB, n = 3; III, n = 12; IVA, n = 2). Ten patients had received previous therapy. The median follow-up duration for the entire cohort is 37 months. Of 63 patients, 51 achieved a complete response (CR; 74.6%) or partial response (PR; 6%) to therapy. The median response duration is 32 months. The 5-year overall survival rate is 91% and the 5-year disease-free survival rate is 75%. No life-threatening side effects were observed. Five patients stopped IFN-alpha-2a therapy due to toxicity. Eighty-four percent of the patients received more than 75% of the planned dose (12 million units three times a week).

CONCLUSIONS

This combination of IFN-alpha-2a and phototherapy is an effective and safe therapy for patients with symptomatic MF.

Practical evaluation and management of cutaneous lymphoma

Accurate evaluation of patients with suspected or known cutaneous lymphoma requires the integration of many sources and types of information, including clinical evaluation, microscopic analysis of tissue, immunophenotyping, gene rearrangement studies, clinical staging, and longitudinal observation. Diagnoses should be based on knowledge of specific lymphoma types as described in modern classification systems. Management of patients with cutaneous lymphoma requires collaboration among dermatologists, dermatopathologists, hematopathologists, and medical, surgical and radiation oncologists. (J Am Acad Dermatol 2002;46:325-57.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should better understand how to evaluate and manage patients for suspected or established lymphoma of the skin. Components include the clinical history and physical examination, optimal biopsy and tissue handling, interpretation of pathology and adjunctive test results, clinicopathologic correlation, and therapy. Participants should also understand the basis for establishing a specific diagnosis of cutaneous lymphoma based on current classification and staging.

Cutaneous lymphomas: which pathological classification?

Cutaneous lymphomas are rare and although some are a manifestation of systemic lymphoma, the majority arise primarily from the skin. These primary cutaneous lymphomas comprise predominantly T cell subtypes and represent a wide spectrum of disorders. Pathologists can currently choose to label these conditions according to three classifications (REAL, EORTC or WHO) but each has shortcomings. Nonetheless, in an attempt to unify the field, we would recommend that pathologists make every attempt to categorise these conditions according to the WHO classification. This classification can encompass all the conditions and aligns the cutaneous lymphomas with the broader systemic lymphoproliferative conditions.

Oral bexarotene in the treatment of cutaneous T-cell lymphoma

OBJECTIVE

To review the preclinical and clinical information related to oral bexarotene approved by the Food and Drug Administration for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma (CTCL) in patients who are refractory to at least one prior systemic therapy.

DATA SOURCES

Literature accessed through MEDLINE (from 1990 to July 2000) and provided by the manufacturer. Key search terms included bexarotene, Targretin, LGD1069, and cutaneous T-cell lymphoma.

DATA SYNTHESIS

The management of CTCL remains controversial due to its rarity in the US and its heterogeneity. An evaluation focusing on the pharmacology of bexarotene and its role in the management of the different stages of CTCL was conducted.

CONCLUSIONS

Bexarotene has demonstrated activity in the treatment of CTCL. The oral route of administration and the adverse effect profile of bexarotene appear to make this drug a favorable option for the treatment of CTCL. Compared with other systemic therapies. Phase III randomized studies are needed to determine the clinical benefits of bexarotene as monotherapy or combination therapy in the treatment of CTCL.

A case of hypopigmented mycosis fungoides

We experienced a 26-year-old woman in whom widespread hypopigmented macules and patches developed as the initial clinical feature of mycosis fungoides. Histopathological examination confirmed the diagnosis. The patients was treated with PUVA, and the lesion progressively disappeared within five months.

Treatment of cutaneous T-cell lymphomas

Primary cutaneous T-cell lymphomas (CTCL), representing a heterogeneous group of non-Hodgkin's lymphomas (NHL), can be defined as clonal proliferation of skin-infiltrating T lymphocytes primarily presenting in the cutaneous compartment. They show a considerable variation in clinical presentation, histology, immunophenotype, and prognosis, which is best reflected by the proposal of the Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer (EORTC). Due to the heterogeneity of CTCL and the lack of curative therapy regimens, multiple strategies have been proposed for the management of the different CTCL entities. This includes topical application of corticosteroids, nitrogen mustard or carmustine (BCNU), radiotherapy, including total skin electron beam irradiation, photo(chemo)therapy, biological response modifiers, cytostatic chemotherapy, and combined regimens. More recently, fusion proteins and peptide vaccines have been introduced in the management of CTCL. Classification, staging, and treatment modalities are discussed in detail and summarized in a stage-adapted therapy regimen for CTCL.

Cutaneous T cell lymphoma: update of treatment

The state-of-the art therapy of cutaneous T cell lymphoma (CTCL) is reviewed. Commonly used treatments for early-stage (patch/plaque) mycosis fungoides (MF) include topical corticosteroids, mechlorethamine, carmustine, ultraviolet light B and PUVA. Total skin electron beam (TSEB) therapy is indicated for widespread infiltrated plaque and tumor stage disease. Low-dose methotrexate is often useful for resistant patch/plaque MF and erythrodermic CTCL. Interferon alpha (IFN-alpha) is indicated for methotrexate failures and recurrent tumors following TSEB therapy. Photopheresis may be helpful for early-stage erythrodermic CTCL but is very costly. Retinoids may be of value for early and moderately advanced CTCL particularly in combination with other agents such as IFN-alpha and PUVA. Systemic disease usually requires combination chemotherapy such as that used for non-Hodgkin's lymphoma; however, responses are usually short lived.

Rare cutaneous malignancies of childhood

Malignant melanoma and mycosis fungoides (cutaneous T cell lymphoma) are rare malignancies in childhood. However, both are potentially fatal tumors that may be cured if detected early. The incidence of melanomas in adolescents has increased in the last 10 years. This makes it imperative that high-risk children be identified for preventive measures including sun protection as well as serial skin examinations. This review highlights the important risk factors for melanoma and comments on which risk-reducing interventions pediatricians should institute. Mycosis fungoides is a cutaneous malignancy usually found in middle-aged adults. Recently, it has been asserted that this entity is underreported in children. This occurs because it may frequently mimic other more common disorders, such as eczema. Thus, lesions clinically suspicious for mycosis fungoides, especially those that have failed chronic eczema therapies, warrant a skin biopsy for definitive diagnosis.

Cutaneous T cell lymphoma in children

Cutaneous T cell lymphoma (CTCL) is a term used to describe a heterogeneous group of lymphoproliferative disorders that involve the skin. Mycosis fungoides and Sézary syndrome are two forms of CTCL that arise in adults and are uncommon in children. Dermatologists frequently employ the term CTCL as a synonym for mycosis fungoides and Sézary syndrome. There has been increased recognition that the mycosis fungoides and Sézary syndrome forms of CTCL may arise in children and adolescents. Moreover, younger adults with these types of CTCL report onset of symptoms during adolescence. The literature regarding CTCL in childhood is limited. The purpose of this article is the review the literature regarding CTCL arising in children. The clinical presentation including morphologic variants, diagnosis, prognosis, and management are summarized.