CASE REPORT
Clinical features: A 52-year-old Saudi male presented to the
Dermatology Clinic at the Armed Forces Hospitals Southern Region, KSA in
2020 with an eight-month history of recurrent itchy scalp lesions. These
skin lesions developed suddenly and increased in size with time. There
was no history of fever, night sweating, weight loss, joint pain, muscle
pain, or loss of appetite. The patient was otherwise medically free with
no history of taking medication or other comorbidities. There was no
family history of similar dermatological problems.
Physical examination revealed multiple well-defined erythematous
telangiectatic infiltrated nodules and plaques associated with hair loss
over the scalp and forehead. There was a poikilodermatous patch over the
skin of the chest. The clinical examination revealed no other
abnormalities. A summary of these findings is shown in Figures 1 and 2.
The clinical impressions included F-MF, follicular lymphomatoid
papulosis, follicular eczema, and pseudolymphomatous folliculitis. All
the laboratory investigations including hematological (complete blood
cell count with differential and peripheral blood) and biochemical
(liver function, urea, electrolyte, lactate dehydrogenase) parameters
were within normal limits. CT scan revealed multiple bilateral cervical
lymph nodes the largest measuring 1.1 x 0.9 cm with preserved fatty
hilum. Although itching was slightly ameliorated with the application of
topical steroids, the lesions did not improve on this treatment. The
patient disappeared and refused any further treatment at our medical
facility.
Pathological findings: A skin 6 mm punch biopsy was obtained.
Sections show deposition of mucin in the follicular epithelium both in
hematoxylin-eosin and PAS/Alcian blue-stained preparations. There was a
dense predominantly perifollicular lymphoid infiltrate. folliculotropism
with infiltration of the mildly hyperplastic follicular epithelium by
atypical small-to-medium-sized lymphocytes infiltrating the follicular
epithelium was seen in all cases. The infiltrate was composed
essentially of lymphocytes with few histiocytes but no eosinophils
(Figure 2-A-F). Infiltration was accompanied by eosinophils and
histiocytes at various rates. There was attenuation of the epidermis
without atypia. There was no epidermotropism. Immunophenotyping revealed
dense dermal (predominantly perifollicular) CD3 and CD4 positive
lymphoid infiltrate (Figure 2-G-H). Occasional CD8-positive dermal T
lymphocytes were seen (CD4: CD8 ratio was more than 7:1) (Figure 2-I).
CD20 showed focal expression in some of the diffusely scattered
lymphocytes. CD30 was negative. A summary of these findings is shown in
Figure 3.