Comedonal folliculotropic mycosis fungoides (FMF): A closer look at MF involving hair collicles

February 27, 2023

Comedonal folliculotropic mycosis fungoides (FMF)

Authors of a nice case report in JAAD Case reports present a patient with comedonal folliculotropic mycosis fungoides (FMF).

They reported a 68-year-old white male presenting for medical attention following a 2-year history of asymptomatic, widespread comedones. He also had patchy alopecia of the scalp and eyebrows and total alopecia of axillary and pubic hair,

Comedonal lesions on on the trunk with accompanying hair loss. SOURCE: Paolino G et al. Widespread and eruptive comedonal lesions with alopecia. JAAD Case Rep . 2022 Nov 1;31:23-26.

Biopsy of a comedonal area showed a dilated, follicular infundibulum with keratotic plugging and a perifollicular band-like CD4-predominant atypical T-lymphocytic infiltrate leading to the detachment and infiltration of the follicles.

Erosive Plaques Followed the Comedonal Lesions

Subsequently, erosive and plaques started to develop on the patient’s trunk and limbs and biopsies were again done showing a more extensive, diffuse, epidermotropic infiltrate containing CD4-predominant T lymphocytes with sparse medium- to large-sized lymphocytes.

DIAGNOSIS

The diagnosis was comedonal folliculotropic mycosis fungoides (FMF). The authors point out that follicular lesions, including comedones, are a very typical presentation of FMF. What was unusual about this case was the fact that widespread comedones as the sole and initial manifestation of FMF is exceedingly rare.

Involvement of the eyebrows is highly characteristic in FMF and may present as an early disease manifestation as well as a useful clue in the differential diagnosis. The authors describe how epidermotropic plaque lesions developing in this patient after many years of comedonal lesions are considered to be indicative of an aggressive course and poor survival in the early stage of the disease.

Treatment for this patient was with was with pegylated interferon alpha-2a and oral isotretinoin. The addition of isotretinoin helps to normalize follicular keratinization, which prevents the formation of new comedo-like lesions. The patient partially benefited from this dual therapy. He experienced hair regrowth and the comedo-like lesions have decreased.