Lymphomatoid papulosis associated with acquired ichthyosis

Acquired ichthyosis: a clinical review

Acquired ichthyosis (AI) is a rare, nonhereditary cutaneous disorder that has been associated with numerous neoplastic, infectious, drugs, endocrine, metabolic, autoimmune, and malabsorptive diseases. Review all demographical, clinical, histological, and therapeutic features of AI and focus on all reported associated diseases. We performed a systematic literature review in Pubmed/Medline, Embase, and Cochrane collaboration databases, searching for all articles on AI, with no limits on publication date, participant age, sex or nationality. Eighty-four articles were included. Total number of included patients was 167 patients with a mean age at presentation of 39 years [range 0.5-85] and a sex ratio M:F of 5:2. The most common malignancy associated with AI is Hodgkin's lymphoma. AI occurred before, simultaneously or after the onset of malignancy or systemic disease. The severity of AI depends on the severity of the underlying disorder and regresses once the disease goes into remission and may also be a marker of disease recurrence or relapse. 8% have been reported to be drug related and all occurred weeks to months after drug intake and resolved after stopping or decreasing the dose of the drug. Data were derived from case reports and observational studies. Limitations include the accuracy of published data, potential patient selection, and reporting bias. AI can be associated with numerous systemic diseases and drugs. Physicians should be particularly alert to these associations to provide adequate screening and management of patients with AI.

Cutaneous paraneoplastic syndromes

A variety of cutaneous abnormalities can be seen in patients with malignant diseases, some of which are infectious, with others representing direct involvement of the skin by the underlying disorder. Yet another group of lesions can be regarded as associated markers of the malignant process, and, as such, are termed "paraneoplastic." This review considers the latter collection of conditions, grouping them by the generic type of malignancy that is usually linked to the paraneoplasia. Some of the processes show a predominant association with alimentary tract malignancies (acanthosis nigricans, acrodermatitis paraneoplastica, florid cutaneous papillomatosis, necrolytic migratory erythema, palmoplantar keratoderma, pancreatic fat necrosis, and pityriasis rotunda). Others are usually linked to a hematolymphoid malignancy (acquired ichthyosis, exfoliative erythroderma, necrobiotic xanthogranuloma, pemphigus paraneoplastica, plane xanthoma, pyoderma gangrenosum, scleromyxedema, Sweet syndrome, and leukocytoclastic vasculitis). Finally, yet another collection of paraneoplastic skin disorders can associate themselves with anatomically-diverse malignancies (Leser-Trelat syndrome, Trousseau syndrome, dermatomyositis, erythema gyratum repens, hypertrichosis lanuginosa acquisita, papuloerythroderma of Ofuji, tripe palms, and multicentric reticulohistiocytosis). Recognition of these processes by the pathologist can be a valuable step in the characterization of underlying malignant diseases.

Acquired ichthyosis

Acquired ichthyosis (AI) is a nonhereditary cutaneous disorder characterized by dry, rough skin with prominent scaling that involves significant portions of the body. It has been associated with malignancies; autoimmune/inflammatory, metabolic, endocrine, and infectious diseases; and medication use. Most microscopic studies of AI exhibit hyperkeratosis with a reduced or absent granular layer. Because AI has been linked to a variety of conditions, the workup of a patient presenting with this finding can be complex. We present an update on AI to provide clinicians with direction regarding the assessment and treatment of patients presenting with AI. An algorithm for the evaluation of patients presenting with AI is provided.

Ichthyosiform mycosis fungoides: An atypical variant of cutaneous T-cell lymphoma

BACKGROUND

Acquired ichthyosis is a known paraneoplastic sign of lymphoproliferative malignancies, with histopathologic findings that are nonspecific, revealing no insinuation of the underlying neoplasm. Ichthyosiform eruption as a specific manifestation of mycosis fungoides (MF), ie, ichthyosiform MF, is, however, regarded as rare and to date has been reported in only a few cases.

OBJECTIVE

We sought to study the clinical, histopathologic, immunohistochemical, and genotypic features of patients with ichthyosiform MF.

METHODS

The files of patients with MF seen during the past 8 years in our department were reviewed to search for cases of ichthyosis-like MF.

RESULTS

Seven patients, comprising 3.5% of the patients seen with MF, had an ichthyosiform eruption with histopathologic features characteristic of early MF. In 2 patients it was the sole manifestation of the disease and in 5 patients it appeared either in conjunction with conventional patches and/or plaques or with follicular lesions. Immunohistochemically, all showed a predominance of CD3+ CD4+, except for 1 patient in whom the epidermotropic T cells were predominantly CD8+. In 3 of the 7 patients clonality could be demonstrated by polymerase chain reaction. None had extracutaneous involvement. All had an indolent course of the disease and responded well to skin-targeted therapies.

CONCLUSIONS

Ichthyosiform MF is yet another atypical clinical variant of cutaneous T-cell lymphoma that is not as rare as reflected in the literature. It may be the sole manifestation of the disease but also may appear in conjunction with conventional or follicular MF lesions.

Anaplastic large-cell lymphoma associated with acquired ichthyosis

Anaplastic, CD30(+), large-cell lymphoma (ALCL) is a subtype of non-Hodgkin's lymphoma that accounts for 2% to 8% of all lymphomas. Its most common form is a classical systemic type, which involves multiple nodal and extranodal sites, including the skin. Malignant lymphoproliferative disorders, especially Hodgkin's disease, are known rarely to be associated with acquired ichthyosis, whereas only 1 case of ALCL has been reported to be associated with acquired ichthyosis. We describe a 74-year-old Japanese man with ALCL, involving lymph nodes and the skin, who exhibited acquired ichthyosis. The clinical and histopathologic findings were recorded, and immunophenotyping, T-cell receptor (TCR), and immunoglobulin gene rearrangement were determined. Clinically, right axillary and bilateral inguinal lymph nodes were palpable. The cutaneous eruptions were multiple pinkish and yellow colored, up to thumb-sized nodules, some of which were ulcerated. Histologically, the right axillary lymph node showed proliferation of anaplastic large cells in the paracortical and sinusoidal areas. Both the lymph node and skin showed pleomorphic proliferation of lymphoid cells with a mixture of mononuclear cells having oval, embryo-shaped, reniform, and lobulated nuclei, binucleated Reed-Sternberg-like cells, and multinucleated cells, with giant anaplastic and wreath-shaped nuclei. Immunophenotyping of the neoplastic cells revealed that they were positive for CD30 (Ber-H2), CD15 (Leu-M1), CD45 (LCA), and CD45RO (UCHL-1). Southern blot analysis demonstrated clonal rearrangement of the TCR beta region. In contrast, no novel bands were detected with the immunoglobulin heavy chain JH probe. Several months after the detection of the axillary nodes, an ichthyosiform, scaly eruption developed over almost the entire body of the patient. Histologically, it showed orthokeratotic, slight hyperkeratosis of the epidermis without a granular layer or with only a single layer of cells in the granular layer. Several kinds of lymphoproliferative diseases are associated with acquired ichthyosis, including Hodgkin's disease, multiple myeloma, and lymphomatoid papulosis. This is the second case report of acquired ichthyosis associated with ALCL. Although a common pathomechanism is suspected of underlying the development of acquired ichthyosis in these diseases, it is still unexplained.

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.