Successful treatment of palmoplantar dyshidrotic lesions of mycosis fungoides with conventional and daylight photodynamic therapy

Abstract

Mycosis fungoides (MF) is the most common subtype of cutaneous T-cell lymphoma. Although early stages of MF generally respond to skin-directed therapies [1], management may be challenging, particularly in some locations [2–8]. Photodynamic therapy (PDT), approved for the treatment of actinic keratoses, Bowen’s disease and superficial basal cell carcinomas [9], is also used off label to treat other conditions, including MF [10]. A 58-year-old woman presented to our department in 2011 with a 5-year history of MF. She had lesions covering more than 10 % of the skin surface (T2bN0B0M0; IB stage), including the palms and soles. In these locations the lesions exhibited a dyshidrosiform appearance. The patient had already received multiple treatments, including topical corticosteroids, oral acitretin, topical PUVA, oral methotrexate and interferon alpha, with unsuccessful response. Oral PUVA resolved all lesions except the palmoplantar plaques (Figure 1a, b). A skin biopsy from the left sole showed intraepidermal spongiform changes and a dermal infiltrate of atypical lymphocytes with epidermotropism (Figure 2). Immunohistochemically, the atypical lymphocytes revealed marked CD3 and CD4 positivity, with near total loss of CD8 and CD7 expression. CD30 was negative. A clonal gamma-chain T-cell receptor gene rearrangement was detected. Therefore, these lesions corresponded to MF plaques despite their particular appearance. We then applied 5 % topical imiquimod on the palms and soles, with poor tolerance and low response. Topical mechlorethamine achieved similar results. As all previous treatments had DOI: 10.1111/ddg.14403 Successful treatment of palmoplantar dyshidrotic lesions of mycosis fungoides with conventional and daylight photodynamic therapy Clinical Letter