Case Reports

Trichodysplasia Spinulosa in the Setting of Colon Cancer

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Trichodysplasia spinulosa (TS) is a rare skin condition seen in immunosuppressed patients that is characterized by folliculocentric papules with central spiny spicules mainly on the face. We report the case of an 82-year-old woman with a history of treated non-Hodgkin lymphoma and a recent diagnosis of stage IV colon cancer. She presented with clinical and histopathologic findings consistent with TS occurring prior to starting immunosuppressive therapy for colon cancer. We conclude that this case of TS may either be secondary to the prior immunosuppressive treatment for the non-Hodgkin lymphoma or that it may represent a paraneoplastic condition warranting appropriate cancer screenings in affected patients.

Practice Points

  • Rashes have a life span and can evolve with time.
  • If apparent straightforward conditions do not appear to respond to standard therapy, start to think outside the box for underlying potential causes.



Case Report

An 82-year-old woman presented to the clinic with a rash on the face that had been present for a few months. She denied any treatment or prior occurrence. Her medical history was remarkable for non-Hodgkin lymphoma that had been successfully treated with chemotherapy 4 years prior. Additionally, she recently had been diagnosed with stage IV colon cancer. She reported that surgery had been scheduled and she would start adjuvant chemotherapy soon after.

On physical examination she exhibited perioral and perinasal erythematous papules with sparing of the vermilion border. A diagnosis of perioral dermatitis was made, and she was started on topical metronidazole. At 1-month follow-up, her condition had slightly worsened and she was subsequently started on doxycycline. When she returned to the clinic again the following month, physical examination revealed agminated folliculocentric papules with central spicules on the face, nose, ears, upper extremities (Figure 1), and trunk. The differential diagnosis included multiple minute digitate hyperkeratosis, spiculosis of multiple myeloma, and trichodysplasia spinulosa (TS).


Figure 1. Trichodysplasia spinulosa with agminated folliculocentric papules with central spicules on the central face (A), ear (B), and bilateral upper extremities (C and D).

A punch biopsy of 2 separate papules on the face and upper extremity revealed dilated follicles with enlarged trichohyalin granules and dyskeratosis (Figure 2), consistent with TS. Additional testing such as electron microscopy or polymerase chain reaction was not performed to keep the patient’s medical costs down; also, the strong clinical and histopathologic evidence did not warrant further testing.


Figure 2. Distended hair bulb, expansion of the inner root sheath, and dyskeratosis (A)(H&E, original magnification ×10). Enlarged trichohyalin granules also were noted on higher power (B)(H&E, original magnification ×40).

The plan was to start split-face treatment with topical acyclovir and a topical retinoid to see which agent was more effective, but the patient declined until her chemotherapy regimen had concluded. Unfortunately, the patient died 3 months later due to colon cancer.

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