J AM ACAD DERMATOL

OCTOBER 2012e148 Letters

Mycosis fungoides following skin trauma

To the Editor: Chronic antigen stimulation is hypoth-esized to play a pivotal role in mycosis fungoides(MF) via accumulation of activated T cells withdeficient cell death.1 Environmental exposures areproposed as one causative factor for the increase inthe incidence of MF.2 We present 4 male patientswhose MF arose after skin trauma.

Case 1. A 36-year-old white man presented with achronic patch of classic poikiloderma vasculare atro-phicans on his right thigh. While running track incollege he had often fallen and gravel was embeddedin this area of the thigh. His abrasions were scrubbedwith harsh antiseptic solution until scar formationdeveloped. Fifteen years later, skin biopsy specimenof a chronic red, white, and brown patch showedatypical lymphocytes infiltrating the papillary dermisand epidermis that met criteria for patch MF and otherlesions appeared on his thighs and buttocks. Topicalclobetasol and 10% nitrogen mustard have resulted inpartial clearing.

Case 2. A 33-year-old white man with stage IA MFreported that his first lesion occurred at age 16 yearswhere he was inoculated on the right buttock withSuper Glue (Super Glue Corporation, RanchoCucamonga, CA). The patch did not resolve withuse of topical creams. Ten years later the lesionenlarged and new pink scaly patches formed on thehips and in the axilla involving 2.5% of his bodysurface area. A biopsy specimen from the rightbuttock revealed epidermotropism and an immuno-phenotype consistent with the CD81 variant of MF.

Case 3. A 46-year-old white man exposed topoison oak on his right thigh developed contactdermatitis that partially resolved leaving a reddishdiscoloration. He applied topical clobetasol thatcleared his lesion but it reappeared 2 years later asa pink patch measuring 9 3 5 cm. Lesional biopsyspecimen revealed an atypical lymphoid infiltratesuggestive of MF. Topical 0.1% triamcinolone creaminduced a long-lasting remission for 10 years.

Case 4. A 38-year-old white man with extensivepoikiloderma vasculare atrophicans was given thediagnosis of MF at age 33 years. He reported that atage 23 years he was involved in an automobile-pedestrian accident that caused a large hematoma todevelop on the front of his right calf. The hematomawas drained several times before it eventually healedleaving mottled hyperpigmentation of overlyingskin. Over the next few years, hyperpigmented dryand pruritic patches extended to his right thigh,abdomen, and opposite leg.

Comments. These 4 male patients each reported atraumatic event at a skin area that evolved over years

to biopsy-proven MF. The median time betweenexposure and diagnosis of MF was 10 years (25% and75% quartiles are 6 and 12.5 years, respectively).Their gender is in accordance with the higher prev-alence of MF in males.2 Previous epidemiologicstudies have yielded conflicting evidence regardingthe risk of occupational and environmental expo-sures in the development of MF.3,4 MF arising at sitesof skin trauma many years later supports the hy-pothesis of Tan et al.1 Persistent antigen stimulation,including environmental exposure, may induce firstan inflammatory reaction that can evolve into clonalT-cell proliferation later recognized as MF.4,5

The authors thank Ping Liu, MS, for her assistance withstatistical analysis in this report.

Laura J. Paul, BS,a and Madeleine Duvic, MDb

University of Texas Medical School at Houstona

and Department of Dermatology, University ofTexas M.D. Anderson Cancer Center, Houstonb

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Madeleine Duvic, MD, Univer-sity of Texas M.D. Anderson Cancer Center,Pickens Tower, FCT11.6078, 1515 HolcombeBlvd, Unit 1452, Houston, TX 77030.

E-mail: mduvic@mdanderson.org

REFERENCES

1. Tan RS, Butterworth CM, McLaughlin H, Malka S, Samman PD.

Mycosis fungoidesea disease of antigen persistence. Br J

Dermatol 1974;91:607-16.

2. Criscione VD, Weinstock MA. Incidence of cutaneous T-cell

lymphoma in the United States, 1973-2002. Arch Dermatol

2007;143:854-9.

3. Whittemore AS, Holly EA, Lee IM, Abel EA, AdamsRM,Nickoloff BJ,

et al. Mycosis fungoides in relation to environmental exposures

and immune response: a case-control study. J Natl Cancer Inst

1989;81:1560-7.

4. Cohen SR, Stenn KS, Braverman IM, Beck GJ. Mycosis fungoides:

clinicopathologic relationships, survival, and therapy in 59

patients with observations on occupation as a new prognostic

factor. Cancer 1980;46:2654-66.

5. Nikkels AF, Quatresooz P, Delvenne P, Balsat A, Pi�erard GE.

Mycosis fungoides progression and chronic solvent exposure.

Dermatology 2004;208:171-3.

http://dx.doi.org/10.1016/j.jaad.2011.11.953

Plantar pustulosis during rituximab therapyfor rheumatoid arthritis

To the Editor: We report a patient with refractoryrheumatoid arthritis (RA), successfully treated withrituximab, who developed plantar pustulosis. A45-year-old female nonsmoker presented with