Leukemia Cutis Follow-up

Author: Jeyanthi Ramanarayanan, MD; Chief Editor: Dirk M Elston, MD more...

Updated: Jun 22, 2010

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Further Inpatient Care
Further Outpatient Care
Inpatient & Outpatient Medications
Transfer
Deterrence/Prevention
Complications
Prognosis
Patient Education
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References

Further Inpatient Care

Further inpatient care is typically determined by a hematologist or an oncologist.

Further Outpatient Care

Further biopsies may be performed as required to rule out recurrences, graft versus host disease after bone marrow transplantation (BMT), or unusual infections resulting from immunosuppression. Appropriate prophylactic antifungal, antiviral, and Pneumocystis carinii pneumonia (PCP) agents and supportive growth factor treatment are needed.

Inpatient & Outpatient Medications

Refer to the individual articles in the eMedicine Journal regarding appropriate chemotherapeutic regimens for the specific subtype of leukemia.

In general, most patients on chemotherapy should receive prophylaxis for common infectious agents, including herpes simplex virus (HSV), Candida species, and P carinii. They should also receive symptomatic treatment for mucocutaneous complications of chemotherapy. These treatments include ketoconazole troches (for thrush) and viscous lidocaine alone or a compound containing lidocaine solution, diphenhydramine hydrochloride, and aluminum hydroxide suspension, ie, "magic mouthwash," (for stomatitis) or chlorhexidine and may relieve symptoms. Symptomatic treatment, including topical steroids, mentholated lotions, or topical lidocaine preparations (Lida-Mantle), for medication- or radiation-induced skin eruptions is often helpful. Preparations containing hyaluronic acid or a medication containing emollients called Biafine can speed the healing of skin with radiation damage.

Transfer

Patients should be primarily cared for by a hematologist and oncologists at a tertiary care medical center.

Deterrence/Prevention

Patients should avoid crowded public places because of the risk of infection. Patients should avoid contact with others who are ill.

Patients should avoid receiving most live vaccines. This may not apply under special circumstances, such as an actual outbreak of smallpox, during which time the risk of death would be greater than the risk of vaccine-associated adverse events. Patients should avoid contact with persons who have been vaccinated with live vaccines.

Complications

Complications include the following:

Infection: As previously mentioned, patients are at risk for a variety of opportunistic infections.
Bleeding: Bleeding as a result of thrombocytopenia is common.
Reactions to chemotherapy
Graft versus host disease: Graft versus host disease following bone marrow transplantation is common.

Prognosis

The prognosis is poor, with many patients having other extramedullary disease and poor survival rates. Most patients die within months of diagnosis. Even patients with aleukemic leukemia cutis or granulocytic sarcoma progress to systemic disease and should be treated systemically from the time of diagnosis.

In a study of 26 patients with cutaneous infiltrates, Kaddu et al reported a median survival of 7.6 months for AML and 9.4 months for chronic lymphocytic leukemia (CLL), regardless of the treatment modality.^[3]

A review of medical literature from 1965-2001 reported an overall survival rate of 6% at 2 years in patients with acute myelogenous leukemia (AML) with leukemia cutis compared with 30% in those without leukemia cutis.

Patient Education

Patients should notify their physician if any fevers or skin eruptions occur.

For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education articles Leukemia and Skin Biopsy.

Contributor Information and Disclosures

Author

Jeyanthi Ramanarayanan, MD Assistant Professor, Department of Medicine, Division of Medical Oncology, Roswell Park Cancer Institute

Jeyanthi Ramanarayanan, MD is a member of the following medical societies: American Association of Physicians of Indian Origin and American Society of Hematology

Disclosure: Nothing to disclose.

Coauthor(s)

Shweta Singhal, MD Resident Physician, Department of Internal Medicine, Rochester General Hospital

Shweta Singhal, MD is a member of the following medical societies: American College of Physicians

Disclosure: Hematology-Oncology None None

Specialty Editor Board

Noah S Scheinfeld, MD, JD, FAAD Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice

Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Optigenex Consulting fee Independent contractor

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

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Agis H, Weltermann A, Fonatsch C, et al. A comparative study on demographic, hematological, and cytogenetic findings and prognosis in acute myeloid leukemia with and without leukemia cutis. Ann Hematol. Feb 2002;81(2):90-5. [Medline].
Kaddu S, Smolle J, Cerroni L, Kerl H. Prognostic evaluation of specific cutaneous infiltrates in B-chronic lymphocytic leukemia. J Cutan Pathol. Dec 1996;23(6):487-94. [Medline].
Baer MR, Barcos M, Farrell H, Raza A, Preisler HD. Acute myelogenous leukemia with leukemia cutis. Eighteen cases seen between 1969 and 1986. Cancer. Jun 1 1989;63(11):2192-200. [Medline].
Shaikh BS, Frantz E, Lookingbill DP. Histologically proven leukemia cutis carries a poor prognosis in acute nonlymphocytic leukemia. Cutis. Jan 1987;39(1):57-60. [Medline].
Cerroni L, Hofler G, Bck B, Wolf P, Maier G, Kerl H. Specific cutaneous infiltrates of B-cell chronic lymphocytic leukemia (B-CLL) at sites typical for Borrelia burgdorferi infection. J Cutan Pathol. Mar 2002;29(3):142-7. [Medline].
Su WP, Buechner SA, Li CY. Clinicopathologic correlations in leukemia cutis. J Am Acad Dermatol. Jul 1984;11(1):121-8. [Medline].
Jones D, Dorfman DM, Barnhill RL, Granter SR. Leukemic vasculitis: a feature of leukemia cutis in some patients. Am J Clin Pathol. Jun 1997;107(6):637-42. [Medline].
Pranteda G, Gueli N, Innocenzi D. Skin vasculitis with direct vessel infiltration by leukaemic cells: a case report. Acta Derm Venereol. Jun-Jul 2001;81(3):215-6. [Medline].
Smoller BR. Leukemic vasculitis: a newly described pattern of cutaneous involvement. Am J Clin Pathol. Jun 1997;107(6):627-9. [Medline].
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Heskel NS, White CR, Fryberger S, Neerhout RC, Spraker M, Hanifin JM. Aleukemic leukemia cutis: juvenile chronic granulocytic leukemia presenting with figurate cutaneous lesions. J Am Acad Dermatol. Sep 1983;9(3):423-7. [Medline].
Chang HY, Wong KM, Bosenberg M, McKee PH, Haynes HA. Myelogenous leukemia cutis resembling stasis dermatitis. J Am Acad Dermatol. Jul 2003;49(1):128-9. [Medline].
Connelly TJ, Kauh YC, Luscombe HA, Becker G. Leukemic macrocheilitis associated with hairy-cell leukemia and the Melkersson-Rosenthal syndrome. J Am Acad Dermatol. Feb 1986;14(2 Pt 2):353-8. [Medline].
Freiman A, Muhn CY, Trudel M, Billick RC. Leukemia cutis presenting with fingertip hypertrophy. J Cutan Med Surg. Jan-Feb 2003;7(1):57-60. [Medline].
Ikeda T, Sakurane M, Uede K, Furukawa F. A case of symmetrical leukemia cutis on the eyelids complicated by B-cell chronic lymphocytic lymphoma. J Dermatol. Jul 2004;31(7):560-3. [Medline].
Ferreira M, Caetano M, Amorim I, Selores M. Leukemia cutis resembling a flare-up of psoriasis. Dermatol Online J. Mar 30 2006;12(3):13. [Medline].
High DA, Luscombe HA, Kauh YC. Leukemia cutis masquerading as chronic paronychia. Int J Dermatol. Nov 1985;24(9):595-7. [Medline].
Simon CA, Su WP, Li CY. Subungual leukemia cutis. Int J Dermatol. Nov 1990;29(9):636-9. [Medline].
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Schwonzen M, Kuehn N, Vetten B, Diehl V, Pfreundschuh M. Phenotyping of acute myelomonocytic (AMMOL) and monocytic leukemia (AMOL): association of T-cell-related antigens and skin-infiltration in AMOL. Leuk Res. 1989;13(10):893-8. [Medline].
Sievers EL, Larson RA, Stadtmauer EA, et al. Efficacy and safety of gemtuzumab ozogamicin in patients with CD33-positive acute myeloid leukemia in first relapse. J Clin Oncol. Jul 1 2001;19(13):3244-54. [Medline].
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Involvement of the face in a patient with acute myelogenous leukemia. Courtesy of Grant Anhalt, MD.

Red-brown papules can be seen in leukemia cutis. They are confluent in this patient. Courtesy of Nevena Damjanov, MD, and Elizabeth Prechtel.

Papules and nodules on the face of an African American patient with acute myelogenous leukemia (AML). Courtesy of Mona Mofid, MD.

A patient with typical plum-colored lesions seen in leukemia cutis. This patient had acute myelogenous leukemia. Courtesy of Grant Anhalt, MD.

This photograph shows linear areas, which are more violaceous in color, likely due to trauma to the area, such as excoriation, which results in hemorrhage into the skin. Frequent hemorrhage into the skin can make any inflammatory skin lesion appear more violaceous in patients with leukemia. Courtesy of Nevena Damjanov, MD, and Elizabeth Prechtel.

Low-power view of leukemia cutis acute myeloblastic leukemia (AML-M1). Note the perivascular and periadnexal infiltrate with relative epidermal sparing. Courtesy of Kim Hiatt, MD.

This is a higher power view of leukemia cutis acute myeloblastic leukemia (AML-M1). This photo illustrates a perivascular infiltrate of leukemic cells. The nuclei are round to oval with little cytoplasm. Courtesy of Kim Hiatt, MD.

Leukemia cutis of acute monocytic leukemia. Perivascular and periadnexal infiltration is also present, but the cell morphology is distinct. Many of the nuclei are folded or indented. The cytoplasm of the leukemic cells is gray-blue and more abundant than in the M1 subtype. Courtesy of Kim Hiatt, MD.

Low-power view of acute promyelocytic leukemia cutis with a perivascular and periadnexal but also interstitial infiltrate, with epidermal sparing but significant upper dermal edema, which could be confused with Sweet syndrome at a low-power view. Courtesy of Kim Hiatt, MD.

Acute promyelocytic leukemia cutis at high power. The round-to-indented nuclei with prominent cytoplasmic granules are evident. Courtesy of Kim Hiatt, MD.

Photo illustrates leukocyte esterase staining of the cytoplasm of the leukemic cells in acute promyelocytic leukemia. Courtesy of Kim Hiatt, MD.

Leukemia cutis at low power demonstrating a Grenz zone and intercalation of leukemic cells between collagen bundles. Courtesy of Keliegh Culpepper, MD.

A higher-power view of intercalation of leukemic cells between collagen bundles. Courtesy of Keliegh Culpepper, MD.

Table 1. Incidences of Types of Leukemia

Type of Leukemia	Incidence in the United States	Percentage of Patients with Leukemia Cutis (%)
AML	2.5 cases per 100,000 population	13
Acute lymphocytic leukemia	1.3 cases per 100,000 population	3
Chronic myelogenous leukemia (CML)	1-2 cases per 100,000 population	2-8
Chronic lymphocytic leukemia (CLL)	2.3 cases per 100,000 population	8
Hairy cell leukemia	0.6-2.9 cases per 1,000,000 population	8
Adult T-cell leukemia	Extremely low	40-70

Table 2. Recommended Immunohistochemical Stains For Leukemia Cutis

Cell Lineage	CD Antigen Marker
T cell	CD45 (LCA) strongly positive CD45RO usually strongly positive CD3 positive but only scattered
B cell	CD20 strongly positive but scattered in normal B cells, weakly positive or negative in abnormal small B cells, positive in abnormal large B cells CD43 usually negative
Granulocytes	Lysozyme strongly positive in well and poorly differentiated granulocytes Chloroacetate esterase positive in well-differentiated granulocytes CD68 usually negative in all granulocytes
Monocytes	Lysozyme strongly positive in well and poorly differentiated monocytes Chloroacetate esterase usually negative CD68 positive in well-differentiated monocytes

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