Dermatology: Practical and Conceptual


Letter  |  Dermatol Pract Concept 2020;10(4):2020069 1

Dermatology Practical & Conceptual

Introduction

Syringotropic mycosis fungoides (STMF) is a rare variant 

of mycosis fungoides (MF) with prominent involvement 

of eccrine structures. It typically presents with red/skin- 

colored/brown papules, patches, scaly plaques, nodules, and 

lichenification, along with pruritus, hair loss, and poor heat 

tolerance and sweating [1]. Whether STMF is a subtype of 

folliculotropic MF (FMF) or a separate entity is still a matter 

of debate [1].  Most STMF patients have a benign, indolent 

course and a better prognosis compared to patients with 

FMF [1]. Histopathology is the gold standard for diagnosis 

of MF and STMF.  

Case Presentation

We present 2 patients with a diagnosis of STMF, both with 

co-expression of CD4+/CD8+.  Patient 1, a 54-year-old man, 

presented with erythematous patches and plaques on the 

neck, face, arms, and back accompanied with pruritus. Di-

agnosis was made using full-thickness skin biopsy; the sites 

were chosen upon dermoscopic examination of the most 

prominent lesions. Few papules and milia-like cysts were 

seen. Other lesions appeared as classical MF both clinically 

and dermoscopically (poorly elevated plaques and dry and 

lichenificated skin). No alopecia, follicular hyperkeratosis, 

or mucinorrhoea were noted; palms and soles were not af-

fected. A diagnosis of folliculotropic and syringotropic MF 

was made. Staging using the WHO/EORTC classification 

indicated stage IB (T2N0M0B0) (Figure 1).

Patient 2, a 64-year-old female, presented with erythe-

matous papules, plaques, comedones, and milia localized on 

the neck and chest (that later progressed to the trunk and 

extremities), accompanied with pruritus. Full-thickness skin 

biopsy was performed after the dermoscopic examination of 

the most prominent skin lesions, and a diagnosis of follicu-

lotropic and syringotropic MF was established (stage IIIB), 

phenotype CD4+/CD8+, CD30-. Staging according to ISCL/

EORTC classification was T4N2M0B0 (Figure 2).

Dermoscopy in both cases showed obliteration of the fol-

licles, follicular accentuation, and follicular plugging (these 

observations for FMF have already been published), along 

Dermoscopy of Syringotropic and Folliculotropic 
Mycosis Fungoides

Ružica Jurakić Tončić1, Jaka Radoš1, Danijela Ćurković, Ivana Ilić2, Stefano Caccavale3,  
Mirna Bradamante1

1 University Department of Dermatology and Venereology, University Hospital Centre and School of Medicine, Zagreb, Croatia

2 University Hospital Centre Zagreb, Department of Pathology and Cytology, University of Applied Health Sciences, Zagreb, Croatia

3 Department of Dermatology, Second University of Naples, Italy

Key words: dermoscopy, primary cutaneous lymphoma, mycosis fungoides, syringotropic mycosis fungoides, folliculotropic mycosis 
fungoides

Citation: Jurakić Tončić R, Radoš J, Ćurković D, Ilić I, Caccavale S, Bradamante M. Dermoscopy of syringotropic and folliculotropic 
mycosis fungoides. Dermatol Pract Concept. 2020;10(4):e2020069. DOI: https://doi.org/10.5826/dpc.1004a69

Accepted: April 21, 2020; Published: October 26, 2020

Copyright: ©2020 Jurakić Tončić et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 
License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium provided the original 
author and source are credited.

Funding: None.

Competing interests: The authors have no conflicts of interest to disclose.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Ružica Jurakić Tončić, MD, University Department of Dermatology and Venereology, University Hospital Center 
and School of Medicine, Kišpatićeva 12, Zagreb, Croatia. Email: rjtoncic@gmail.com 



2 Letter  |  Dermatol Pract Concept 2020;10(4):2020069

that this kind of bluish color is commonly observed with 

other eccrine type of tumors (such as eccrine hidrocystoma) 

[2]. Accumulation of pigmented substances in eccrine glands 

was excluded by the pathologist; therefore, the bluish color 

is not a result of this kind of pigmentation.

Conclusions

Since currently there is no data on dermoscopic images of 

STMF, and these 2 patients differ in stage of the disease, we 

calculate that the differences observed are due to the stage 

of the disease and probably correspond to severity of the 

infiltration of eccrine ducts with atypical lymphocytes (stag-

ing of the patients). In order to understand this entity more, 

with loss of terminal follicles, comedo-like openings, and 

interconnected regular-appearing structureless patches [1] 

(Figures 1 and2). Orange color and follicular plugging were 

seen, corresponding to dense, diffuse, and perifollicular lym-

phocytic infiltrate. Similar observations were made in both 

patients, with one major distinction. We have never observed 

the bluish structures with unsharp borders before in FMF 

patients, as in the case of Patient 2, who presented with more 

advanced disease. These structures were not observed in 

pure FMF (Figure 2). There are probably 2 explanations for 

this observation. In the Patient 1, histology showed that fol-

licles were more prominently affected and dermoscopic im-

ages correlated more with FMF, while in the Patient 2 eccrine 

glands were predominantly affected. It is interesting to note 

Figure 1. Patient 1. Clinical and dermoscopic presentation: dermoscopic images were taken from the lesion on which biopsy was done. The 

lesion was on the brachial region of the patient. Along with typical dermoscopic presentation of MF on other parts of the body, on selected 

body parts, lesions presented with follicular accentuation and with follicular plugging. Follicular accentuation and plugging were more visible 

when higher magnification was used. Clinical staging of the patients at the time of evaluation was T2N0M0B0. (A) Clinical presentation of 

lesion from where the biopsy was taken. (B-C) Dermoscopy of the lesion from where the biopsy was taken. (D) Dermoscopy of the skin from 

the presternal area. (E-H) Histologic presentation of the lesion from where the biopsy was done. (E) Follicular and ecrrine gland involvement 

by dense infiltrate of atypical lymphocytes (H&E, ×4). (F) Marked folliculotropism, peri- and intrafolllicular lymphoid infiltration with mucin 

deposition (H&E, ×10). (G) Syringometaplastic structures of eccrine glands surrounded and infiltrated by atypical lymphocytes (H&E, ×20). 

(H) Immunohistochemical staining was positive for T lymphocytes (CD4; ×4) (I) Lymphocytic infiltrate was composed of CD3+ lymphocytes 

(×4). Clinical photography was taken with a Canon Powershot SX520 HS and the dermoscopic image with a Nikon/DermLite Photo.

A B C

D E F

G H I



Letter  |  Dermatol Pract Concept 2020;10(4):2020069 3

and pseudolymphomas presenting as solitary nodules and tu-

mors: a case-control study with histopathologic correlation. 

Int J Dermatol. 2019;58: 1270-1276. DOI: 10.1111/ijd.14590. 

PMID: 31347153.

2. Duman N, Duman D, Sahin S. Pale halo surrounding a ho-

mogeneous bluish-purplish central area: dermoscopic clue for 

eccrine hidrocystoma. Dermatol Pract Concept. 2015;5:43-45. 

DOI: 10.5826/dpc.0504a11. PMID: 26693090.

we need dermoscopic studies with a larger number of the 

patients in different stages of the disease.

References

1. Navarrete-Dechent C, Del Puerto C, Abarzúa-Araya Á, et al. 

Dermoscopy of primary cutaneous B- and T-cell lymphomas 

Figure 2. Patient No 2. Clinical and dermoscopic presentation of the lesion on the face.  In this patient follicular accentuation is less visible, 

follicular obliteration and plugging are more pronounced, and bluish, not well-defined areas are seen  Clinical staging of the patients at the 

time of evaluation was T4N2M0B0. (A) Clinical presentation of the lesion from where biopsy was taken. (B-D) Dermoscopic appearance  

of the lesion from where the biopsy was taken. Dermoscopy shows obliteration of the follicles and in some parts bluish, not well -defined 

structures where eccrine involvment was found. (E-H) Histology of the lesion from where biopsy was taken. (E) Atypical lymphocytes 

surround and invade follicular epithelium (H&E, ×10). (F) Atypical lymphocytes were positive for CD3+ on immunohistochemistry (×10). 

(G) CD3+ lymphocytes have a predilection for  eccrine ducts (×20). (H) Infiltration of eccrine ducts with atypical small to medium-sized 

lymphocytes (H&E, ×20). Clinical photography was taken with a Canon Powershot SX520 HS and the dermoscopic image with a Nikon/

DermLite Photo.

A B C D

E F G H