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The many faces of mycosis fungoides

Mycosis fungoides is not a common condition, although it is the commonest form of cutaneous lymphoma. There is often a delay in initial diagnosis because it can appear similar to other inflammatory conditions such as eczema, psoriasis, and dermatophyte infection. It may progress from patch to plaque to tumours stages slowly, but there are some clues that should alert one to the diagnosis.

Initial patch lesions tend to be asymmetric and may have scalloped irregular margins and fine scale. Some lesions will show poikiloderma, that is atrophy, telangiectasia, and pigmentation. Light-shielded areas are favoured.  

Folliculotropic disease has a predilection for hair follicles which can become plugged, and have a nutmeg grater-like feel and pustules may develop beneath the plugs. Darker skin types may show hypopigmentation. Plaques may be irregularly scattered and can be polycyclic or arciform. 

Initial biopsies can be reassuring as there is so often a lag between clinical suspicion and histological confirmation. Tumours are more obvious and histology usually unequivocal.

So, if conditions are not responding as you would expect, keep MF in the back of your mind, and do not be shy about rebiopsy!

Early patch stage mycosis fungoides – there is fine scale and increased pigmentation and fine atrophy and wrinkling. Failure to improve as one may expect with appropriate eczema or fungal infection treatment can be a clue.

 

Early plaque stage mycosis fungoides – the lesions are now palpable and have irregular edges.   

                                                     

Plaque stage mycosis fungoides – lesions are irregularly and asymmetrically arranged on the torso. 

                                         

Patch and folliculotropic mycosis fungoides – there is a follicular predilection which gives a spiny feel similar to a nutmeg grater.             

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