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Leukemia Cutis Treatment & Management

  • Author: Kyle Devins; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Feb 24, 2015
 

Medical Care

Leukemia cutis is a local manifestation of an underlying systemic disease; therefore, it should be managed with systemic chemotherapy. Literature on aleukemic leukemia cutis is limited, but because diagnosis of leukemia cutis portends poor prognosis in acute leukemia, the treatment should be directed at eradicating the leukemic clone by using aggressive systemic chemotherapy and stem cell transplant possibly in first remission.

The treatment of leukemia should be determined by the subtype of leukemia and by the patient's ability to tolerate a treatment regimen. This is primarily dependent on the overall medical condition of the patient, including any comorbid conditions that may exist. Under certain circumstances, such as resistant or recurrent skin disease, local treatment in the form of electron beam therapy can be used. However, in most of these cases, reinduction systemic chemotherapy must be added unless medically contraindicated by the patient's comorbidity.

Refer to Acute Myelogenous Leukemia and Acute Lymphoblastic Leukemia.

Radiation therapy

Radiation therapy can be used to palliate symptoms of pain and pruritus in patients with leukemia cutis who are not candidates for systemic chemotherapy. Addition of radiation therapy to skin lesions after complete response to systemic chemotherapy provides no additional benefit. In a rare instance, radiation may be used to treat isolated skin relapse when bone marrow shows complete remission and no other site of extramedullary relapse is evident. If these patients are subsequently treated with chemotherapy, reports detail severe radiation recall phenomenon occurring with chemotherapy drugs like cytarabine and clofarabine.[40]

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Surgical Care

Most patients require central venous catheter placement for chemotherapy delivery, if they do not have one.

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Consultations

Consult a hematologist and an oncologist if the patient presents with aleukemic leukemia cutis. Consult with a bone marrow transplantation physician if the patient is a candidate for such intensive therapy. Consider a consultation with a radiation oncologist for skin-directed therapy, if appropriate.

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Diet

Neutropenic patients may be placed on diet of well-cooked foods with avoidance of deli meats, fresh fruits, and fresh vegetables to avoid associated risk of infection.

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Activity

Patients may be cautioned to avoid strenuous activity.

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Contributor Information and Disclosures
Author

Kyle Devins State University of New York Upstate Medical University

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas N Helm, MD Clinical Professor of Dermatology and Pathology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences; Director, Buffalo Medical Group Dermatopathology Laboratory

Thomas N Helm, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society of Dermatopathology

Disclosure: Nothing to disclose.

Robert E Kalb, MD Clinical Professor, Medical Student and Resident Instructor, Department of Dermatology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences; Adjunct Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Robert E Kalb, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

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

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania 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, Society for Investigative Dermatology, Association of Professors of Dermatology, North American Hair Research Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

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

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.

Acknowledgements

Jeyanthi Ramanarayanan, MD Assistant Professor, Medical Oncology, Veterans Affairs Medical Center of Buffalo

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.

Adrienne Rencic, MD, PhD, FAAD Consulting Staff, Department of Dermatology, Riddle Memorial Hospital

Adrienne Rencic, MD, PhD, FAAD is a member of the following medical societies: National Psoriasis Foundation

Disclosure: Nothing to disclose.

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: Nothing to disclose.

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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.
Infiltration of leukemic cells between collagen bundles.
Infiltration of dermoepidermal junction by clonal T cells in Sézary syndrome.
Diffuse macules and papules on the scalp of a patient with chronic myelogenous leukemia.
Gingival infiltration in a patient with acute myelogenous leukemia.
Diffuse truncal eruption of infiltrated papules and plaques in chronic lymphocytic leukemia.
Close-up photo of diffuse truncal eruption of infiltrated papules and plaques in chronic lymphocytic leukemia.
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



CD43 positive, MPO sometimes positive



Monocytes Lysozyme strongly positive in well and poorly differentiated monocytes



Chloroacetate esterase usually negative



CD68 positive in well-differentiated monocytes



CD163 less sensitive but more specific than CD68



CD117



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