mycosis fungoides ( mf ) is the commonest variant of primary cutaneous t cell lymphoma , accounting for almost 50% of all primary cutaneous lymphomas [ 1 , 2 ] .
typically , neoplastic t cells localize to the skin and produce patches , plaques , tumors or erythroderma .
it is characterized by a relatively consistent constellation of clinical , histologic , immunophenotypic and molecular aberrations .
mf typically manifests as an indolent cutaneous eruption with erythematous scaly patches or plaques and may progress to generalized erythroderma , cutaneous tumors , or extracutaneous involvement .
tumors , however , develop only in a minority of patients from patches , plaques , or de novo .
leonine facies results from malignant t cell infiltration leading to extensive thickening and skin fold accentuation .
classically , mf shows a cd2 + , cd3 + , cd4 + , cd8 , cd30 , cd45ro+ immunophenotype .
rare cases with a t suppressor cd8+/cd4 phenotype have been reported [ 8 , 9 ] .
this report describes the clinical , histopathologic and immunohistochemical features of a patient with mf mimicking psoriasis vulgaris .
a 52-year - old white man was referred to the department of dermatology , university of palermo ( italy ) with a six - month history of psoriasiform plaques with superficial erosion and fissuring on the palms ( fig .
red violet and infiltrated plaques with moderate hyperkeratosis and scaling developed on the scalp and upper limps accompanied by itching .
four months prior to referral he developed red to violaceous nodules which coalesced to form large plaques on the face .
skin examination at the time of hospital admission , approximately six months from the onset of his illness , revealed reddish brown ulcerated tumors and indurated erythematous plaques with superficial erosion on the forehead , glabella , cheeks ( fig .
1 a ) , scalp and neck . in addition , numerous plaques , accompanied by itching , were found on trunk and extremities in a generalized distribution .
plaques appeared as sharply delineated , scaly , elevated lesions that were dusky red to violaceous and variably indurated ( fig
the blood count showed normal red cell count and a slight leukocytosis ( 11.42  10/l ) comprised of 74.6% neutrophils , 7.2% eosinophils , 0.7% basophils , 11.1% lymphocytes and 6.4% monocytes .
further laboratory investigations of the blood showed alpha 1-globulin 5.25% and an erythrocyte sedimentation rate of 44 mm / h .
a biopsy specimen was obtained from affected areas of the face , fixed in 10% buffered formalin and embedded in paraffin . for routine histology
chest x - ray , total body computed tomography scanning and excisional biopsy of the inguinal lymph node were obtained .
review of the face biopsy on hematoxylin and eosin showed a dense , partly subepidermal and band - like , partly perivascular and periadnexal dermal infiltrate ( fig .
2 a ) containing a high number of atypical lymphocytes , eosinophils , plasma cells and macrophages . many of the lymphocytes were pleomorphic , hyperchromatic , hyperconvoluted and had an increased cytoplasmic to nuclear ratio .
mild acanthosis , hyperkeratosis , basal layer damage , edema and fibrosis of the papillary dermis and moderate proliferation of postcapillary venules were also seen .
immunohistologically the malignant cells expressed a mature peripheral t cell phenotype ( cd3 + , cd4 + , cd45ro+ , cd8 , cd20 ) ( fig .
total body computed tomography scanning was obtained documenting retroauricular , occipital , deep cervical lymphatic chain , submandibular , submental , axillary , subclavian and inguinal enlarged lymph nodes without visceral involvement .
findings were consistent with tumor stage mf ( stage iib , t3 n1 m0 ) .
mf is generally an indolent malignancy , with slow progression over years or even decades .
the onset of the disease is often insidious and initial cutaneous symptoms may be difficult to distinguish from various inflammatory dermatoses such as chronic eczema , psoriasis , atopic dermatitis , etc . [ 8 , 11 ] . as the disease progresses , patches may evolve over a variable period of time into infiltrated plaques with a more generalized distribution .
tumors develop only in a minority of patients , although it is common to have patch , plaque and tumor lesions simultaneously on different parts of the body .
visceral dissemination ( lungs , spleen , liver , gastrointestinal tract ) may develop subsequently .
extracutaneous dissemination is directly correlated to the extent of cutaneous disease [ 7 , 10 ] .
we report a patient who first showed hyperkeratotic psoriasiform plaques on the palms and soles .
involvement of the palms and/or soles occurs at some time during the course of the disease in 11.5% of patients .
mycosis fungoides palmaris et plantaris is a rare variant of mf - type cutaneous t cell lymphoma predominantly affecting or initially presenting on the palms and/or soles .
the prevalence of mycosis fungoides palmaris et plantaris among mf patients is 0.6% . in most cases
the disease shows a benign course ; the lesions remain confined to the initial areas without dissemination and extracutaneous spread [ 12 , 13 ] . in our patient tumors in the skin and lymphadenopathy developed rapidly over a two - month time span without lengthy preceding erythematous or plaque stages .
the time interval between onset of skin changes and definite pathologic diagnosis of mf is 46 years [ 10 , 14 ] . in the present case the lesions developed into a leonine clinical appearance of the face accompanied by lymphadenopathy , which reminded us the tumor stage mf .
based on the early involvement of extracutaneous sites , the course of this patient may be more aggressive than typical patch - stage disease , in which mortality is not significantly different from matched controls .
the presence of tumor stage disease is associated with a worse prognosis ( stage iib : median survival of 2.9 years ) .
mf is an uncommon lymphoma with a wide spectrum of clinicopathological manifestations and unpredictable course .
diagnosis can be difficult in its early stages given the considerable overlap with more common benign dermatoses .
 mycosis fungoides ( mf ) is an uncommon primary cutaneous lymphoma with a wide spectrum of clinicopathological manifestations . 
 diagnosis can be difficult in its early stages given the considerable overlap with more common benign dermatoses . 
 we report an unusual case of mf in a 52-year - old male presenting with psoriasiform plaques on the palms and the soles who rapidly developed additional lesions on the scalp , limps and trunk . 
 punch biopsy of the face was obtained for routine histology and immunohistochemical stains . 
 chest x - ray , total body computed tomography scanning and excisional biopsy of the inguinal lymph node were performed . 
 review of the face biopsy revealed a diffuse dermal infiltrate containing a high number of atypical lymphocytes showing a cd3 + , cd4 + , cd45ro+ , cd8 , cd20 immunophenotype and epidermotropism . 
 findings were consistent with tumor stage mf ( stage iib , 
 t3 n1 m0 ) . 
 we report a rare presentation of mf mimicking psoriasis vulgaris . 
Introduction
Case Report
Results
Discussion