Inflammatory vitiligo versus hypopigmented mycosis fungoides in a 58-year-old Indian female
A 58-year-old Indian female presented to our office complaining of a 3-year history of white patches on her face, neck, trunk, and extremities. New lesions were continuing to develop, with the left anterior leg and right wrist being the most recently affected sites. Past medical history was significant only for osteoporosis and the patient denied taking any medications. She admitted to a trip to India several years prior but had no other recent travel. A review of systems was negative, with the patient denying pain, pruritus, dysesthesia, peripheral neuropathy, and alopecia of the scalp or eyebrows.\nOn physical examination, speckled, depigmented macules and patches on the eyelids, forehead, cheeks, neck, and hands were appreciated. In addition, hypopigmented patches with scaly, raised, erythematous borders were observed on the back, abdomen, legs, thighs, and buttocks [Figures –]. No hypoesthesia or dysesthesia of the patches was noted. There was no loss of hot or cold sensation within or surrounding the patches.\nAn in-office KOH was negative for fungal organisms. A punch biopsy was taken from the right lower back at the margin of a hypopigmented patch that was surrounded by erythema []. This revealed: “spongiosis, a superficial perivascular and interstitial scattering of lymphocytes in a papillary dermis of altered collagen, scattered single necrotic keratinocytes, multifocal vacuolar alteration of the junction, and mounds of parakeratosis” [Figures and ]. A second biopsy taken from the right medial buttock [] showed “superficial perivascular and sparse interstitial infiltrate of lymphocytes with a rare eosinophil, wiry bundles of collagen in the papillary dermis, mild spongiosis, lymphocytes sprinkled within the epidermis, and mounds of parakeratosis []. CD4 and CD8 stains demonstrated a helper: suppressor ratio of greater than 5:1 [Figure and ]. A CD7 stain demonstrated staining of approximately 30% of lymphocytes []. Further staining with Melan-A demonstrated a marked reduction of melanocytes but not complete absence []. Given the patient's previous report of travel to India, leprosy had been a consideration clinically but neither granulomas, foamy macrophages, nor perineural inflammation were identified histopathogically. A Fite-Faraco stain was also negative. With some worrisome features for mycosis fungoides, including wiry bundles of collagen, inflammatory infiltrate, and mild exocytosis, a polymerase chain reaction (PCR) assay for rearranged T-cell receptor gamma genes was obtained. This showed polyclonality, with the intensity of peak not consistent with that seen in clonal neoplasms.\nGiven the clinical findings of several classic appearing depigmented patches on the forehead, eyelids, and dorsal hands, the inflammatory nature of the lesions from which the biopsies were taken, the near-total loss of melanocytes evident with Melan-A staining, and PCR findings demonstrating a lack of monoclonality, the diagnosis of inflammatory vitiligo was favored. However, hypopigmented MF could not be definitively ruled out and the coexistence of two separate disease processes remained a possibility. Therefore, close follow-up of this patient remains important.