Lymphomatoid papulosis

Localized lymphomatoid papulosis: Unilesional lymphomatoid papulosis, regional lymphomatoid papulosis, and persistent agmination of lymphomatoid papulosis

Lymphomatoid papulosis (LYP), the most common primary cutaneous CD30-positive lymphoproliferative disorder, is heralded by multiple papular and nodular lesions at anatomically discontiguous cutaneous sites. The histologic patterns are protean. An uncommon form of LYP is one that is anatomically confined. Cases of unilesional LYP, regional LYP, and persistent agmination of LYP were encountered in the routine and consultative practices of Weill Cornell Medicine, Division of Dermatopathology. The clinical presentation, outcomes, light microscopic findings, and phenotypic profile are reviewed. There were 10 cases of LYP presenting as solitary plaques or nodules primarily occurring in older patients and without a relevant medical history in most. Most cases occurred at an acral site with many localized to the foot; the morphology was one of a necrotizing angiocentric type E pattern and borderline type C morphology. Two of the unilesional patients in our series went on to develop mycosis fungoides, one at the initial site of unilesional type A LYP, and the other at a discontiguous site. Excluding one case, the solitary lesions underwent complete regression; after the lesions regressed, some cases had no apparent recurrence. The second anatomically confined variant of LYP in our series was regional LYP exhibiting a type E morphology in two cases and a hybrid type A and granulomatous eccrinotropic morphology in one case. There was no subsequent development of lymphoma, nor was there any spread to additional anatomic sites. The final category was persistent agmination of LYP, whereby the agminated papules of LYP were superimposed on a plaque of cutaneous T-cell lymphoma represented by mycosis fungoides in two and follicular helper T-cell lymphoma in one. In conclusion, anatomically confined LYP defines an uncommon form of LYP, but it is an important one to recognize because the histology can be worrisome despite an indolent clinical course. The clinical presentation, the infrequent association with lymphoma/leukemia, and histology are similar to conventional LYP, although there appears to be a greater tendency for complete regression without recurrence, excluding cases of persistent agmination of LYP whereby the clinical course warrants categorization as a form of cutaneous T cell lymphoma (CTCL).

Lymphomatoid Papulosis Associated with Cutaneous T-Cell Signet Ring Lymphoma

The authors describe a new case of cutaneous T-cell lymphoma of signet ring cell type with CD-30 (Ki-t) expression. The patient was a 52-year-old woman with a 20-year history of recurrent papulonodular lesions characteristic of lymphomatoid papulosis (LP). Subsequent to developing the signet ring cell lymphoma (SRL) the patient's cutaneous lesions did not resolve as previously, and a skin biopsy showed a diffuse proliferation of atypical lymphoid cells with cytoplasmic vacuoles. SRL was first reported in 1985 by Weiss, and a literature search found only six further reports since then. Vaillant suggests that the peculiar morphology is retated to the special indolent course of this condition and that the cutaneous form should be considered a distinct entity. This is the first report of a patient with LP who subsequently developed a cutaneouis T-cell signet ring lymphoma with CD-30 antigen expression. The case could be an example of a so-called borderline lymphoma.

Consequences of misdiagnosis of lymphomatoid papulosis

We report two patients with lymphomatoid papulosis (LyP), who were initially diagnosed as systemic T-cell lymphoma. The patients presented with recurrent self-healing cutaneous lesions and skin biopsies showed a lymphocytic infiltrate with malignant features. Clinico-pathological correlation of findings was not performed and results of staging investigations were misinterpreted. Consequently, both patients were unnecessarily treated with multi-agent chemotherapy, radiotherapy and stem cell/bone marrow transplants and sustained long-term adverse effects. The clinical and histological features of LyP are described and appropriate management discussed in detail. Factors leading to the unnecessary treatment of both patients are examined and several learning points highlighted such as the importance of a multidisciplinary approach.

Éruptions varioliformes aiguës: aspects diagnostiques et évolutifs

INTRODUCTION

Abrupt onset of papular lesions, with ulcero necrotic evolution could refers to many dermatitis. Febrile ulceronecrotic Mucha-Habermann disease is an unusual severe form of pityriasis lichenoides and varioliform acuta (PLEVA) characterized with ulceronecrotic eruption potentially associated with high fever and systemic symptoms leading to death. Lymphomatoid papulosis is a recurrent papulonodular eruption with an initial presentation close to PLEVA. While this disorder usually has a benign course, about 10% of the patients develop lymphoproliferative disorders such as CD30+ lymphoma.

EXEGESIS

The authors reported an acute form of PLEVA in a young man hospitalized in internal medicine unit with fever and ulcero-necrotic papulo-vesicular lesions. Treatment with tetracycline was successful. They also report a case of lymphomatoïd pustulosis that occurred in a 34 years old woman with an extensive nodulo-pustular eruption characterized by central necrosis and ulceration. Histopathological examination revealed CD30 lymphocytic infiltration leading to diagnosis.

CONCLUSION

Theses two dermatosis, uncommon and clinically similar, are both characterized with an unpredictable evolution that to be known by internist.

Lymphomatoid papulosis in a patient with Waldenström's macroglobulinemia

Lymphomatoid papulosis (LyP) is a rare skin disease with a benign course but a malignant histologic appearance based on atypical lymphocytes. Waldenström's macroglobulinemia (WM) is a diffuse infiltration of the bone marrow by cells that synthesize IgM immunoglobulins. A 46-year-old female presented with a two year history of weakness, fatigue, anemia, and recurring multiple erythematous papules and nodules in the skin. The skin biopsy showed pleomorphic lymphoid cells with atypical mitoses permeated by a diffuse dermal infiltrate of normal appearing lymphocytes. The neoplastic cells were positive for CD30, CD3, and CD5 but negative for CD20 and EMA. The bone marrow was hypercellular due to a diffuse infiltration by lymphocytes, plasma cells, and plasmacytoid lymphocytes. LyP is a lymphoproliferative disorder of CD30-positive T cells that may be associated with other lymphoid malignancies, particularly Hodgkin's disease, mycosis fungoides, and anaplastic T cell lymphomas. To our knowledge, this is the first report of a LyP appearing in a patient with WM.

Lymphomatoid papulosis from childhood with anaplastic large-cell lymphoma of the small bowel

Lymphomatoid papulosis (LyP) is a lymphoproliferative disorder that exists on a spectrum of diseases with cutaneous CD30+ anaplastic large-cell lymphoma (ALCL). Multiple treatment options are available, although none are curative. The typical age of onset for LyP is in the third and fourth decades, but it has been seen occasionally in children. Lymphomatoid papulosis is associated with primary cutaneous ALCL and other lymphoproliferative malignancies, but is rarely associated with extranodal systemic ALCL. A 43-year-old man developed lymphomatoid papulosis lesions at 3 years of age, which persisted into adulthood, and he later developed ALCL of the duodenum. Treatment with standard CHOP (cyclophosphamide/doxorubicin/vincristine/prednisolone) chemotherapy resulted in complete remission of his gastrointestinal lymphoma and temporary improvement of his skin lesions. However, the LyP relapsed and proved refractory to psoralen plus ultraviolet-A phototherapy, and was only temporarily and partially responsive to bexarotene and denileukin diftitox.

Oral Involvement in Lymphomatoid Papulosis

Oral involvement in cutaneous CD30+ T-cell lymphoid proliferations is rare and has received little attention in the dermatologic literature. The authors report 2 patients with self-healing, recurrent papulonodular eruptions with the classic clinical, histopathological and immunophenotypic features of lymphomatoid papulosis, which developed two ulcerated papules and an ulcerative nodule on the dorsum of the tongue, respectively. The lesions appeared coincident with a new cutaneous relapse of the disease. Histopathological and immunophenotypic features were similar to those of the cutaneous lesions. All lesions regressed spontaneously after several weeks. Since then, and after follow-up periods of 3 and 7 years, respectively, no evidence of extracutaneous involvement has been detected. Oral involvement in lymphomatoid papulosis is an uncommon event, probably without prognostic significance. Previously reported cases are reviewed. The differential diagnosis of atypical T-cell lymphoid infiltrates observed in the oral mucosa is discussed.

Lymphomatoid papulosis in an HIV-positive man

Lymphomatoid papulosis (LyP) is a rare cutaneous lymphoproliferative condition characterized by a chronic, recurrent eruption of papules and nodules that undergo spontaneous regression. The disorder is usually clinically benign; with a minority of cases progressing to malignant lymphoma. LyP is divided into two subtypes based on histologic appearance. Type A resembles Hodgkin's disease with up to 20% of large CD30+ lymphocytes. Type B resembles mycosis fungoides showing an infiltrate of CD4+ lymphocytes and scattered CD30+ cells. Clinically LyP often resembles pityriasis lichenoides et varioliformis acuta but has a strikingly different histological appearance. Histologically, LyP resembles lymphoma (anaplastic T-cell or Hodgkin's) but is distinguished by its benign course. Here we present a case of LyP in a severely immune-repressed HIV-positive patient. This patient presented with pruritic papules involving the upper extremities and a CD4+ T-cell count of 4. Histopathologic examination showed a dense superficial dermal infiltrate comprising normal-sized lymphocytes admixed with larger lymphocytes. Immunophenotyping showed most of the lymphocytes to be CD3+ (T cells). The scattered larger cells were CD30+. The smaller lymphocytes were CD8+ rather than CD4+ as expected for non-HIV-appointed LyP. This may be because of the immune disregulation of HIV disease and the absolute and relative paucity of CD4+ T cells relative to CD8+ T cells.

Topical methotrexate for lymphomatoid papulosis

Lymphomatoid papulosis is a lymphoproliferative disease characterized by recurrent papules, nodules, or plaques that spontaneously involute within several weeks. Despite having a histologically malignant-appearing infiltrate, patients with lymphomatoid papulosis have a clinically benign course. Several treatment options have been described for the management of lymphomatoid papulosis. We describe a patient who had complete resolution of lesions with the use of topical methotrexate.

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.

Coexistence of CD30-positive anaplastic large cell lymphoma and mycosis fungoides

Primary cutaneous T-cell lymphomas, including lymphomatoid papulosis, mycosis fungoides and CD30+ anaplastic large cell lymphoma (ALCL) overlap clinicopathologically and form part of a spectrum of lymphoproliferative disorders. There have been several case reports of these diseases coexisting. We describe a 59-year-old Korean man who presented with a recurrent, solitary CD30+ ALCL of 25 years' duration as well as patch stage mycosis fungoides of 11 years' duration. Such occurrences may represent different clinical manifestations of the same clonal T-cell abnormality, and provide further insight into the pathogenesis of these related disorders.

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 T-cell lymphoproliferative disorders: approach for the surgical pathologist: recent advances and clarification of confused issues

Cutaneous T-cell lymphoproliferative disorders (CTCLs) remain a subject of confusion and controversy. In this review, the authors discuss diagnostic criteria and classification, including the role of immunohistochemistry and gene rearrangement studies. In addition, cutaneous T-cell pseudolymphomas, the current status of parapsoriasis and other premalignant syndromes, and the clinicopathological variants of mycosis fungoides are discussed. CD30-positive lymphoproliferative disorders and a number of rare variants of CTCL including granulamatous slack skin, subcutaneous (panniculitic) T-cell lymphoma, gamma-delta cutaneous lymphoma, NK/NK-like T-cell lymphoma, and primary cutaneous CD8-positive epidermotropic cytotoxic T-cell lymphoma are also considered.

Lymphomatoid papulosis associated with both severe hypereosinophilic syndrome and CD30 positive large T-cell lymphoma

BACKGROUND

Previous reports have found an association between lymphomatoid papulosis and hypereosinophilic syndrome, as well as lymphomatoid papulosis and lymphoma. In the current study the authors report what to their knowledge is the first reported case of these three diseases occurring simultaneously in the same patient.

METHODS

The authors followed the clinical course of a 64-year-old man with lymphomatoid papulosis associated with severe hypereosinophilic syndrome complicated by involvement of the lungs and heart.

RESULTS

After 6 years of follow-up, the patient developped a large T-cell, CD30 positive lymphoma. The bone marrow biopsy was typical of hypereosinophilic syndrome associated with fibrosis, with focal lymphomatous infiltrates comprised of large cells resembling the type A cells of lymphomatoid papulosis. Complete remission of the lymphoma was obtained with chemotherapy.

CONCLUSIONS

This exceptional case report suggests a link between the three diseases. Lymphomatoid papulosis belongs to the spectrum of CD30 positive lymphoproliferative disorders and CD30 positive lymphocytes of lymphomatoid papulosis are known to have a Th2 profile with possible secretion of eosinopoietic cytokines.

Primary cutaneous T-cell lymphoma: review and current concepts

PURPOSE

Primary cutaneous T-cell lymphomas (CTCLs) encompass a wide variety of lymphomas that are characterized by the localization of the malignant lymphocytes to the skin at presentation. Advances in molecular biologic techniques, including immunophenotyping and gene rearrangement studies to determine clonality, have led to more frequent diagnosis of CTCL as well as more consistent subclassification of these entities. However, there continues to be confusion in the classification, prognosis, and management of patients with CTCL. The purpose of this review is to present a summary of the diagnosis, prognosis, and treatment of CTCL, with specific emphasis on mycosis fungoides (MF) and Sézary syndrome (SS). We also present a detailed discussion of the entities that make up the differential diagnosis of CTCL.

DESIGN

We reviewed the medical literature on CTCL and other diseases that make up the differential diagnosis of CTCL.

RESULTS AND CONCLUSION

MF and SS are the most common forms of CTCL. The etiology of this disease is still unknown. Patients may go for months to years with skin abnormalities before being diagnosed. MF/SS is an indolent disease and patients with T1 disease have a normal life expectancy. Patients who undergo transformation to large-cell lymphoma (8% to 23% of patients) have a poor prognosis, with mean survival ranging from 2 to 19 months. Treatment for MF/SS continues to be palliative. There are many new therapies that are currently being investigated in clinical trials, and the DAB(389)IL-2 fusion protein was recently approved for the treatment of refractory MF/SS.

A case of mycosis fungoides after CD30 positive anaplastic large cell lymphoma

A 55-year-old woman presented with mycosis fungoides (MF) after the total excision of primary cutaneous CD30+ anaplastic large cell lymphoma (ALCL). In the specimens obtained from the nodule of CD30+ ALCL and the plaque lesion of MF, the same pattern of T-cell receptor gene rearragement was detected.

Development of IgG lambda multiple myeloma in a patient with cutaneous CD30+ anaplastic T-cell lymphoma

We report a patient with an epidermotropic cutaneous T-cell lymphoma which transformed into an anaplastic cutaneous CD30+ T-cell lymphoma. Repeated relapses required prolonged systemic PUVA therapy. Two years after diagnosis, the patient had several episodes of infections of the respiratory tract. Serum electrophoresis now revealed significantly reduced polyclonal immunglobulin production and an additional band in the gamma fraction corresponding to IgG lambda monoclonal gammopathy. Thereafter, the patient suffered a pathologic fracture of the dorsolateral 5th rib on the right side and an accumulation of monoclonal plasma cells in the bone marrow confirmed the diagnosis of multiple myeloma (IgG lambda). Accordingly, 6 cycles of cytoreductive chemotherapy (alkeran, decortin) were given. After one year of steady state disease the patient lost weight and bone pain increased while only a few papular eruptions were detectable. Radiography showed multiple small osteolytic areas. A few months later he died with signs of bone marrow insufficiency.

Involvement of the tongue by lymphomatoid papulosis

We report on a case of lymphomatoid papulosis (LyP) with involvement of the tongue. The patient was a 34-year-old Japanese man. Three reddish, centrally depressed, slightly elevated nodules were evident on the dorsal tongue, along with lesions elsewhere on the skin. One of them was biopsied and exhibited a superficial and deep, perivascular and interstitial mixed cellular infiltrate including atypical lymphoid cells, lymphocytes, neutrophils, and histiocytes. The patient also showed rhythmical recurrence of reddish papules and ulcerated nodules on the trunk, extremities, and anogenital area. Histologically, these papules showed a dense, wedge-shaped mixed cellular infiltrate in the dermis, which included medium and large atypical lymphoid cells, lymphocytes, neutrophils, and histiocytes. Immunoperoxidase staining for CD30 was positive in the cell membrane and cytoplasm of the atypical cells. We could not find other reports of LyP involving the tongue. Systemic treatment with interferon (INF)-alpha2a was dramatically effective in inhibiting recurrence of the eruption.

Cutaneous pseudolymphomas

Cutaneous pseudolymphoma refers to a heterogeneous group of benign reactive T- or B-cell lymphoproliferative processes of diverse causes that simulate cutaneous lymphomas clinically and/or histologically. The inflammatory infiltrate is bandlike, nodular, or diffuse and is composed predominantly of lymphocytes with or without other inflammatory cells. Depending on the predominant cell type in the infiltrate, cutaneous pseudolymphomas are divided into T- and B-cell pseudolymphomas. Cutaneous T-cell pseudolymphomas include idiopathic cutaneous T-cell pseudolymphoma, lymphomatoid drug reactions, lymphomatoid contact dermatitis, persistent nodular arthropod-bite reactions, nodular scabies, actinic reticuloid, and lymphomatoid papulosis. Cutaneous B-cell pseudolymphomas include idiopathic lymphocytoma cutis, borrelial lymphocytoma cutis, tattoo-induced lymphocytoma cutis, post-zoster scar lymphocytoma cutis, and some persistent nodular arthropod-bite reactions. This review attempts to discuss current aspects of the classification, pathogenesis, clinical spectrum, histopathologic and immunohistochemical diagnosis, and laboratory investigations for clonality in the various types of cutaneous pseudolymphomas.

Traumatic eosinophilic granuloma of the oral mucosa: a CD30+(Ki-1) lymphoproliferative disorder?

Traumatic eosinophilic granuloma of the oral mucosa, also known as eosinophilic ulcer, is considered to be a reactive lesion of unknown aetiology. It usually presents as a tongue ulcer and injury has been considered to play a role in its cause. We present a 72-year-old man who had suffered multiple episodes of recurrent eosinophilic ulcers of the oral mucosa which underwent self-healing. Biopsy specimens (including fresh tissue) were studied with a combination of histology, electron microscopy and immunohistochemistry. A dense cell infiltrate composed of eosinophilis, lymphocytes and large mononuclear cells was constantly shown. Immunostains showed that the infiltrate was mainly composed of CD3+,CD4+,CD8-T-cells and CD1a + dendritic cells. Approximately 70% of the T-cells expressed CD30 (Ki-1) antigen. On the basis of the clinical behaviour, histology and antigenic features, it seems reasonable to suggest that traumatic eosinophilic granuloma of the oral mucosa may represent the oral countpart of primary cutaneous CD30 (Ki-1)-positive lymphoproliferative disorders. This group of cutaneous lymphomas are indeed characterised by non-aggressive clinical behaviour (sequential evolution in ulceration, necrosis and self-regression) and expression of CD30 antigen by the infiltrating large T-cells.

Is it lymphoma or lymphomatoid papulosis?

Distinguishing malignancy from premalignant conditions can be difficult. Controversy surrounds both the clinical and histologic criteria used to distinguish lymphomatoid papulosis, a benign disorder, from CD30+ anaplastic large-cell lymphoma. Three case histories illustrate important points in categorizing different lymphoproliferative disorders as benign or malignant. We emphasize a multidisciplinary approach to improve diagnosis and patient management.

Lymphomatoid papulosis: successful weekly pulse superpotent topical corticosteroid therapy in three pediatric patients

Lymphomatoid papulosis is a T-cell proliferation that occurs primarily in adults but has been well described in children. Lesions may regress spontaneously but often leave residual scarring and, as a result, intervention frequently is considered. Therapeutic modalities commonly employed for adults with lymphomatoid papulosis may be poorly tolerated by pediatric patients. We present a series of three children with lymphomatoid papulosis treated with superpotent topical corticosteroids (halobetasol or clobetasol propionate). When applied twice daily for 2 to 3 weeks followed by weekly pulsed application, this treatment resulted in complete resolution of nearly all cutaneous lesions. Three ulcerated lesions, occurring in two patients, required adjuvant therapy with intralesional triamcinolone. To date one patient remains free of cutaneous disease and two children experience occasional new lesions that respond to renewed treatment with topical clobetasol propionate. None of the children have evidence of systemic disease. We conclude that pulsed application of a superpotent topical corticosteroid is efficacious and safe in the management of cutaneous lesions of lymphomatoid papulosis and avoids the risks often associated with more aggressive interventions. Since these agents do not alter the risk of subsequent malignancy, careful ongoing surveillance of children with lymphomatoid papulosis is imperative.

Mycosis fungoides presenting as an acquired ichthyosis

A 25-year-old patient with an acquired ichthyosis-like condition is described. Histologic and molecular biologic examination of the fine, whitish, scaling skin lesions suggested the diagnosis of mycosis fungoides. Typical lesions of mycosis fungoides, such as patches, plaques, or tumors, were not present. To the best of our knowledge, this is the first case of mycosis fungoides presenting solely with the clinical features of acquired ichthyosis. The sudden appearance of ichthyosiform skin changes in adults must be taken seriously and the underlying cause must be evaluated. A skin biopsy should be performed in all cases of acquired ichthyosis to rule out mycosis fungoides.

Eosinophilic histiocytosis. Histopathology and immunohistochemistry

We review the clinical features, histopathology, and immunohistochemistry in three cases of eosinophilic histiocytosis, comparing lymphomatoid papulosis and eosinophilic histiocytosis. Each of the patients presented with self-healing recurrent papules and ulcerative nodules that were associated with pruritus. Disease duration was 5 months to 9 years. Histologically, the lesions demonstrated spongiosis and lymphocytic exocytosis, epidermal hyperplasia, papillary dermal edema, and a superficial and deep mixed perivascular inflammatory infiltrate. The infiltrate showed numerous eosinophils, histiocytoid cells, lymphocytes, and large mononuclear cells with atypical hyperchromatic nuclei. Most of the lymphocytes and large mononuclear cells with atypical nuclei marked with UCHL-1 (T-cell marker). The histiocytoid cells marked with S-100 and were dendritic both in the epidermis and the dermis. Eosinophilic histiocytosis appears to differ from classic lymphomatoid papulosis. It presents with recurrent papules and nodules associated with marked pruritus. Eosinophilic histiocytosis uniformly has more eosinophils and does not have the Reed-Sternberg cells often observed in lymphomatoid papulosis type A. Eosinophilic histiocytosis does not have cells that mark with Ki-1 and shows numerous S-100-positive histiocytoid cells that are most likely Langerhans cells, unlike lymphomatoid papulosis. However, eosinophilic histiocytosis may be an unusual Ki-1-negative variant of lymphomatoid papulosis with histopathologic changes not typical of type A or type B. In addition, eosinophilic histiocytosis lacks multinucleated histiocytes and the atypical histiocyte with a reniform nucleus, findings that are characteristic of histiocytosis X. Further studies are needed to define the pathophysiology and prognosis of this apparently distinct entity more accurately.

Methotrexate is effective therapy for lymphomatoid papulosis and other primary cutaneous CD30-positive lymphoproliferative disorders

BACKGROUND

The spectrum of primary cutaneous CD30+ lymphoproliferative disease consists of lymphomatoid papulosis (LyP) at one extreme and CD30+ peripheral T-cell lymphoma (Ki-1+ lymphoma) presenting in the skin at the other extreme. Methotrexate has been reported to be effective in LyP, but the experience has been limited to single case reports or small series.

OBJECTIVE

The objective was to determine the effectiveness of methotrexate in the treatment of primary cutaneous DC30+ lymphoproliferative disease.

METHODS

We reviewed our 20-year experience with the use of methotrexate in 45 patients with relatively severe LyP, Ki-1+ lymphoma, and interface presentations.

RESULTS

During induction of methotrexate therapy patients received maximum doses ranging from 10 to 60 mg/week (median, 20 mg/week). Clinical improvement usually occurred quickly, typically at doses of 15 to 20 mg weekly, and satisfactory long-term control was achieved in 39 patients (87%) with maintainance doses given at 10 to 14-day intervals (range, 7 to 28 days). After methotrexate was discontinued, 10 patients remained free of CD30+ lesions from more than 24 months to more than 227 months (median, more than 127 months). The median total duration of methotrexate therapy for all patients exceeded 39 months (range, 2 to 205 months). Adverse effects were generally mild and transient and included fatigue (47%), nausea (22%), weight loss (13%), diarrhea or gastrointestinal cramping (10%), increased serum hepatic transaminase levels (27%), anemia (11%), or leukopenia (9%). Early hepatic fibrosis was found in 5 of 10 patients, all of whom had been treated for more than 3 years (range, 38 to 111 months).

CONCLUSION

Low-dose methotrexate (25 mg or less given at 1-to 4-week intervals) is an effective and well-tolerated treatment of selected patients with primary cutaneous CD30+ lymphoproliferative disease.

Symmetrical lymphomatoid papulosis masquerading as pyoderma chancriformis of the eyelids

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