Hurricane Katrina evacuee develops a persistent rash
A disease that’s easy to mistake for vitiligo
The hypopigmented spots of CTCL look so much like vitiligo, it is frightening to think how easy it would be to miss the diagnosis. Complicating matters: All vitiligo does not need a biopsy to confirm the clinical impression.
So what made this case suspicious enough to warrant a biopsy? First, the hypopigmented spots on our patient were not a typical distribution for vitiligo, which has a predilection for the hands and face. Second, our patient had a hypopigmented patch that had a dark, slightly raised plaque within it, which also would not be typical for vitiligo. (See the patient’s left upper thigh, just below the inguinal area, in FIGURE 1.) Finally, our patient had a rapid onset of multiple discrete macules that did not coalesce into larger hypopigmented areas; in vitiligo you would expect otherwise.
The differential diagnosis also includes idiopathic guttate hypomelanosis, a benign condition that can cause multiple small hypopigmented macules. The size of immunoglobulin H macules, however, is tiny compared with what you’ll see with CTCL. The absence of scales makes eczema, psoriasis, or tinea corporis very unlikely.
Treatment starts with topical steroids
This is a rare disease that lacks the data needed to support an evidence-based approach to treatment. Topical steroids are recommended for stage I when the disease is local to the skin (see TABLE for recommended treatments of other stages). Ultraviolet light (PUVA and UVB) is also used; a recent study suggests the PUVA is a good treatment alternative for stages IA and IB (SOR: C).1
Our patient’s course
Initially, we prescribed a high-potency generic steroid (clobetasol 0.05% cream) for this patient, to be used twice daily to the affected areas.
The patient reported no improvement with this approach, while she awaited her appointments with dermatology and oncology specialists.
Her blood tests were essentially normal, including a negative HIV test.
She is currently receiving narrowband UVB treatment twice weekly.
