|Year : 2016 | Volume
| Issue : 2 | Page : 144-146
Cutaneous pseudolymphoma: A case report
Mayur Bhobe, Naguesh Pai Kakode, Shubhlaxmi Pednekar, Varadraj Pai
Department of Skin (DVL), Goa Medical College, Goa, India
|Date of Web Publication||30-Jun-2016|
Department of Skin, Goa Medical College, Goa
Source of Support: None, Conflict of Interest: None
Pseudolymphomas are a group of disorders, which clinically and histopathologically mimic lymphomas. A 38-year-old female presented with a plaque over the forehead. A biopsy revealed a nodular infiltrate of lymphocytes that was suggestive of pseudolymphoma. The lesion spontaneously regressed over 9 days of biopsy, leaving behind hyperpigmentation.
Keywords: Cutaneous lymphoid hyperplasia, pseudolymphoma, regressed spontaneously
|How to cite this article:|
Bhobe M, Kakode NP, Pednekar S, Pai V. Cutaneous pseudolymphoma: A case report. Muller J Med Sci Res 2016;7:144-6
| Introduction|| |
Cutaneous pseudolymphoma refers to a heterogeneous group of benign reactive T- or B-cell lymphoproliferative processes of diverse causes that simulate cutaneous lymphomas clinically and/or histologically.
| Case Report|| |
A 38-year-old female presented with a single asymptomatic erythematous annular plaque 4 × 3.5 cm over the forehead since 2 weeks [Figure 1]. The plaque was firm and nontender. Sensations were normal over the plaque. The lesion reportedly began as a reddish, small, round, raised lesion that had gradually increased to the current size. There was no nerve enlargement. There was no clinical evidence of sensory or motor deficit. She also gave history of a similar lesion over right forearm 8-10 months ago that had spontaneously subsided over 2 weeks. There was no history of photosensitivity. She gave no history of insect bite or any recent travel. There was no history of prior drug intake. She had no history of cough, fever, or weight loss.
|Figure 1: Annular plaque 4 × 3.5 cm over forehead with dilated follicular orifices|
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The patient was investigated with a differential diagnosis of granuloma faciale, pseudolymphoma, borderline tuberculoid Hansen's disease, and sarcoidosis. Biopsy showed a dense diffuse and nodular infiltrate involving the upper dermis sparing the subepidermal zone and collagen bundles. The infiltrate was composed of lymphocytes and histiocytoid cells and a few eosinophils involving the whole of the reticular dermis and extending to the subcutis. Most of the nodules showed the formation of lymphoid follicles. A number of blood vessels was seen within the lymphoid follicles. These features were suggestive of pseudolymphoma [Figure 2] and [Figure 3]. The infiltrate was superficially located (top heavy) and polymorphic, and there was formation of germinal centers. There was a proliferation of blood vessels. The above features helped to differentiate it from lymphoma histopathologically. Immunohisochemistry could not be done as the patient could not afford it. The plaque progressed over the next 4 days after presentation; however, it gradually regressed spontaneously over the next 5 days leaving behind hyperpigmentation.
|Figure 2: [H and E 10×] Dense nodular infiltrate composed of lymphocytes and histiocytes with formation of lymphoid follicles. Infiltrate spares the subepidermal zone|
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|Figure 3: [H and E 40×] Infiltrate composed of lymphocytes, histiocytes, and a few eosinophils|
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| Discussion|| |
Pseudolymphoma is the term used to describe skin lesions that simulate lymphoma, primarily histologically but sometimes clinically, which at the time of diagnosis appears to have a benign biologic behavior and does not satisfy the criteria for malignant lymphoma. Based on their lymphoid subset composition, they have been divided into T- and B-cell pseudolymphomas. Cutaneous T-cell pseudolymphomas include idiopathic cutaneous T-cell pseudolymphoma, lymphomatoid drug reactions, lymphomatoid contact dermatitis, persistent nodular arthropod-bite reactions, nodular scabies, actinic reticuloid, and lymphomatoid papulosis.  Cutaneous B-cell pseudolymphomas (CBPL) include idiopathic lymphocytoma cutis, borrelial lymphocytoma cutis, , tattoo-induced lymphocytoma cutis, , post-zoster scar lymphocytoma cutis, , pseudolymphomas posttrauma,  gold pierced earings,  and some persistent nodular arthropod-bite reactions.  Cutaneous lymphoid hyperplasia (CLH) is the preferred term to denote B-cell pseudolymphomas.
They are usually seen as a single asymptomatic soft, doughy, or firm nodule or tumor measuring up to 4 cm in diameter; lesions may be aggregated in small clusters. The color varies from skin-colored to red to red-brown to red-purple. Scale and ulceration are generally absent. 
Histopathology of pseudolymphoma shows the presence of a polymorphous infiltrate, which tends to be more superficially located (top heavy) with sparing of the epidermis and the narrow papillary dermis. Germinal centers can be divided into two types:
- The small-cell nodular form that shows typical germinal center formation and lacks cellular pleomorphism, and
- The large cell nodular form that has large pleomorphic lymphocytes and frequent mitotic figures that can be difficult to distinguish from lymphoma.
Other cell types that may be found in germinal centers are T-helper cells, macrophages with tingible bodies (nuclear fragments of lymphocytes within macrophages), and dendritic cells. Plasma cells may be the predominant cells. ,
The most important feature is the presence of B lymphoctes with polyclonal light chains (a mixture of lambda and kappa light chains in the B cells) in CBPL, in contrast to cutaneous B-cell lymphomas (CBCLs) in which one light chain predominates. ,
MT2/CD45RA expression is exclusively restricted to follicular CBCL, whereas germinal centers of CBPL are negative. 
The histologic features that favor CBPL over CBCL include:
- A top-heavy infiltrate,
- A mixed cellular infiltrate,
- Presence of germinal centers,
- A presence of tangible bodies (fragmented basophilic nuclear debris of degenerated lymphoid cells),
- Vascular proliferation,
- Preservation of the adnexal structures, and
- The appearance of the germinal centers. 
The infiltrate in lymphomas tends to be monomorphous, dense, and located deeply in the dermis and subcutaneous tissue (bottom heavy). 
They tend to resolve within weeks to months. If the lesion persists, then a punch biopsy is indicated to confirm the diagnosis and to rule out other conditions; it might also be curative. 
Treatment options include exision, topical steroids, intralesional steroids, antibiotic, tacrolimus, systemic steroids hydroxychloroquine, and photodynamic therapy. This case has been reported for its self-resolving nature after biopsy.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]