I first saw Michael in early 2007. He came in with a generalized reddish, scaly, peeling eruption that was covering him from head to toe. He was desperate as he was seen by several other dermatologists searching for an effective treatment. My differential diagnosis whenever I see a diffused generalized reddish eruption is a type of psoriasis, severe form of eczema, other autoimmune processes, possible infection, and very rarely cutaneous T-cell lymphoma or mycosis fungoides.
At that time, I jumped the gun and instinctively felt the patient had atopic dermatitis and placed him on cyclosporine which is a very effective medication. However, as I was curious and suspicious as well as wanting to cover all bases, I performed three biopsies. I rushed the processing of the biopsies. A few days later I received a call that he had mycosis fungoides/cutaneous T-cell lymphoma and the treatment with cyclosporine was contraindicated. We immediately contacted the patient to stop the cyclosporine and referred him for management of his cutaneous T-cell lymphoma.
This disease appears differently in each patient with skin symptoms manifesting as patches, plaques, or tumors. Patches are usually flat, possibly scaly, and look like a rash; plaques are thicker, raised, usually itchy lesions that are often mistaken for eczema, psoriasis, or dermatitis; and tumors are raised bumps, which may or may not ulcerate. It is possible to have more than one type of lesion.
Now, 10 years later, I am pleased to report that Jack is in great health after having multiple treatments. He eventually had a bone marrow transplantation that gave him the ultimate response to get better.
Since this occurrence, every time I see a red scaly peeling eruption, I remember Jack and his case always reminds me how diligent we should be in establishing the correct diagnosis especially when we anticipate a long term condition to treat, establishing a correct diagnosis from day one is extremely important.
As my professor from 30 years ago used to tell me, “the gods want a diagnosis before they start a treatment”.