An 85 year-old man with no significant past medical history complained of an itchy eruption for one year. The lesions began on his back and gradually spread over his arms, buttocks, face, and legs. Two previous biopsies were reportedly negative for malignancy. Treatment with topical corticosteroids provided some relief of his pruritus, but there was no improvement in the skin lesions. He was on no new medications and had no history of fevers or other systemic symptoms. Review of systems was negative. Three additional biopsies showed dilated hair follicles with increased mucin and a mixed lymphohistiocytic infiltrate with eosinophilia. There were no atypical lymphocytes. Colloidal iron staining confirmed the presence of markedly increased dermal mucin in the follicular epithelium. Immunostaining revealed CD3+/CD4+/CD5+ diffusely in all three specimens, with only scant CD8 positivity. One specimen revealed CD3 positivity with prominent exocytosis into the epidermis. No hyperconvoluted mycosis cells were seen.
Laboratory studies showed the following: CD3+ Abs 2187 cells/mcL (ref: 840-3060); CD3+/CD4+ Abs 946 cells/mcL (ref: 490-1740); CD3+/CD8+ Abs 1183 cells/mcL (ref: 180-1170); CD4:CD8 ratio 0.8 (ref: 0.86-5.00); Sezary prep: pending.
CBC: elevated WBC at 11.6 thous/mcL (ref: 3.8-10.8; diff: 65.5% neutrophils, 24.2% lymphocytes, 0.7% eosinophils, 0.2% basophils), otherwise unremarkable. CMP: Unremarkable. Chest x-ray: negative. T-Cell gene rearrangement studies: pending. He was diagnosed with follicular mucinosis and treated with clobetasol 0.05% ointment twice daily for his body and hydrocortisone valerate 0.2% cream twice daily for the face.
well-demarcated, erythematous, hyperpigmented patches and indurated plaques as well as follicular, erythematous papules and clusters of large, open comedones