deep dermis (Figure 3b). Despite the atypical sparing of palms and soles, the biopsy findings supported a diagnosis of toxic erythema of chemotherapy, likely secondary to cytarabine. The patient was instructed to apply triam- cinolone ointment 0.1% twice daily to affected areas. DISCUSSION Leukemia cutis is the extramed- ullary infiltration of malignant he- matopoietic cells in the epidermis, dermis, or subcutis. 1 This neoplastic leukocytic infiltrate is associated with acute monocytic leukemia, acute my- elomonocytic leukemia, and chronic lymphocytic leukemia. 1 The clinical presentation can include macules, papules, plaques, nodules, and ulcers, which can be localized or dissemi- nated. 2 Following the establishment of a diagnosis with the gold standard of a tissue biopsy, curative treatment is aimed at elimination of the systemic leukemia through a combination of chemotherapy and radiotherapy. 1 Chemotherapeutic agents can cause a broad range of overlapping cutaneous reactions characterized by areas of painful erythema, collectively referred to as toxic erythema of chemo- therapy (TEC). 3 TEC includes Burg- dorf’s Reaction, erythrodysesthesia, acral erythema, toxic acral erythema, eccrine squamous syringometaplasia, epidermal dysmaturation, epidermal dystrophy, hand-foot syndrome, palmar-plantar erythema, palmar- plantar dysesthesia, and neutrophilic eccrine hidradenitis. 3 TEC occurs from 24 hours to 10 months following the use of chemotherapeutic agents such as cytarabine, anthracyclines, 5-fluo- rouracil, capecitabine, and taxanes. 4,5 Clinically, patients present with erythematous and occasionally edem- atous plaques, typically affecting the palms and the soles, that may be associated with pain, burning, and tenderness. 2-4,8 While several cases in the literature describe involvement in intertriginous areas such as the axillae and groin, as well as other sites such as the elbows and knees, the majority of these documented manifestations
Figure 1: Focal leukemic infiltrative pattern with large, atypical mononuclear cells with slightly eccentric basophilic nuclei, single nucleoli, scant cytoplasm. (Hematoxylin-eosin stain, 20x)
Figure 2: (a) Circumferential erythematous plaques on wrists with sparing of palms. (b) Erythematous, scaly plaque on left dorsal hand and forearm with sparing of metacarpalphalangeal, proximal interphalangeal, and distal interphalangeal joints.
Figure 3: (a) Pseudoepitheliomatous hyperplasia of epidermis. (b) Extensive syringo- metaplasia in mid to deep dermis.
J La State Med Soc VOL 166 November/December 2014 237
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