Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2023;13(1):e2023047 1 Dermoscopic Evolution of Mycosis Fungoides After Allogeneic Hematopoietic Stem Cell Transplantation: a Case Series Grażyna Kamińska-Winciorek1, Anastazja Szlauer-Stefańska1, Włodzimierz Mendrek1, Sebastian Giebel1 1 The Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Gliwice Branch, Poland Key words: dermoscopy, cutaneous T-cell lymphomas, allogeneic hematopoietic stem cell transplantation, lymphoma, hematologic neoplasms Citation: Kamińska-Winciorek G, Szlauer-Stefańska A, Mendrek W, Giebel S. Dermoscopic Evolution of Mycosis Fungoides After Allogeneic Hematopoietic Stem Cell Transplantation: a Case Series. Dermatol Pract Concept. 2023;13(1):e2023047. DOI: https://doi. org/10.5826/dpc.1301a47 Accepted: September 22, 2022; Published: January 2023 Copyright: ©2023 Kamińska-Winciorek et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Grażyna Kamińska-Winciorek, Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Gliwice Branch, Poland; Wybrzeże Armii Krajowej 15, 44-101 Gliwice, Poland. Telephone: +48604070208 E-mail: dermatolog.pl@gmail.com Introduction Allogeneic hematopoietic stem cell transplantation (alloHSCT) is a potentially curative treatment in patients with mycosis fungoides (MF) and may be used in selected patients with advanced disease [1]. The differentiation of MF relapse from other skin diseases that occur after transplanta- tion is challenging. In this case series we present the dermo- scopic observation of MF lesions after alloHSCT. Case Presentation We have performed a dermoscopic follow-up of MF skin lesions in 3 patients before and after alloHSCT. Dermo- scopic images were captured using the DermLite Cam with polarized light and independently analyzed by two certified dermoscopists (G.K-W, A.SZ-S), blinded to the clinical status of the disease. The progression was determined as new MF lesions were confirmed in the histopathologic examination. The details of the disease, alloHSCT procedure and der- moscopic assessment are presented in Table 1. Treatment was tolerated well, and there was no case of transplant- related mortality. In active MF, red and orange color of the background was found with the presence of numerous dotted and/or linear vessels, distributed unspecifically, uniformly, or in clusters. In one case increased white and yellow scaling was noted in patchy distribution. In cases of disease regression, a visible change in background color was noted (from red to skin-colored or light brown) (2/3), with the disappearance of the previously described vessels. 2 Research Letter | Dermatol Pract Concept. 2023;13(1):e2023047 Ta b le 1 . D er m o sc o p ic a ss es sm en t o f sk in l es io n s in t h e co u rs e o f al lo ge n ei c h em at o p o ie ti c st em c el l tr an sp la n ta ti o n f o r m yc o si s fu n go id es . Pa ti en t ca se n u m b er ; G en d er 1 ; M 2 ; F 3 ; F C o n d it io n in g re gi m en ; D o n o r; I m m u n o su p p re ss io n F lu d ar ab in e+ M el p h al an ; M U D ; C sA + M tx T SI + T L I+ A T G ; M U D ; C sA + M M F F lu d ar ab in e+ T B I; M U D ; C sA O ve ra ll r es p o n se ( ti m e af te r al lo H SC T ) P R , t h en P D ( tr ea te d w it h D L I) , t h en P R ( 5 ,5 y ea rs ) C R ( 3 y ea rs ) P D ( 1 0 0 d ay s) D ay ( al lo H SC T i s d ay 0 ) - 1 + 1 4 + 4 1 + 6 9 6 -1 + 1 4 + 2 7 + 8 7 -1 + 1 4 + 5 6 + 1 0 0 Sc al e (c o lo r an d d is tr ib u ti o n ) W h it e an d ye ll ow p at ch y - - - - - - - - - - - O th er s tr u ct u re s (c o lo r an d m o rp h o lo gy ) - - b ro w n p ar al le l li n es b ro w n p ar al le l li n es gr ey d o ts a n d gl o b u le s; w h it e an gu la te d li n es gr ey d o ts a n d gl o b u le s; w h it e an gu la te d li n es w h it e d if fu se st ru ct u re le ss ar ea s; g re y d o ts a n d gl o b u le s w h it e d if fu se st ru ct u re le ss ar ea s; b ro w n d o ts an d g lo b u le s w h it e fo ca l st ru ct u re le ss ar ea s; b ro w n gl o b u le s w h it ef o ca l st ru ct u re le ss ar ea s; b ro w n li n es w h it e fo ca l st ru ct u re le ss ar ea s; b ro w n f o ca l gl o b u le s w h it e fo ca l st ru ct u re le ss ar ea s V es se ls d is tr ib u ti o n a n d m o rp h o lo gy u n sp ec ifi c d o tt ed cl u st er ed d o tt ed - - u n if o rm d o tt ed u n if o rm d o tt ed p er ip h er al d o tt ed - u n sp ec ifi c li n ea r u n sp ec ifi c li n ea r u n sp ec ifi c li n ea r u n sp ec ifi c d o tt ed a n d li n ea r C o lo r o f th e b ac k gr o u n d re d , o ra n ge (s al m o n ) o ra n ge (s al m o n ) sk in -c o lo re d sk in -c o lo re d re d a n d p u rp le o ra n ge (s al m o n ) o ra n ge (s al m o n ) li gh t b ro w n sk in -c o lo re d sk in -c o lo re d sk in -c o lo re d sk in -c o lo re d A b b re vi at io n s: a ll o H SC T - al lo ge n ei c h em at o p o ie ti c st em c el l tr an sp la n ta ti o n ; A T G - an ti th ym o gl o b u li n ; C sA - cy cl o sp o ri n e A ; C R - co m p le te r em is si o n ; D L I- d o n o r ly m p h o cy te i n fu si o n ; F - fe m al e; M - m al e; M M F - m yc o p h en o la te m o fe ti l; M tx - m et h o tr ex at e; n o - n u m b er ; M U D - m at ch ed u n re la te d d o n o r; P D - p ro gr es si ve d is ea se ; P R - p ar ti al r em is si o n T B I- t o ta l b o d y ir ra d ia ti o n ; T L I- t o ta l ly m p h at ic i rr ad ia ti o n ; T SI -t o ta l sk in i rr ad ia ti o n . Research Letter | Dermatol Pract Concept. 2023;13(1):e2023047 3 Dermoscopy in the setting of alloHSCT may help to differentiate between a variety of skin conditions after the procedure, including relapse of the primary disease, cutane- ous graft versus host disease, drug-induced rashes, infectious skin disorders, and secondary cutaneous neoplasms. Der- moscopy is an auxiliary tool in the differentiation of inflam- matory disorders and MF based on the vessels’ morphology and their distribution, color of the background, color and distribution of the scales [2]. Dermoscopic features of MF described in the litera- ture include short linear and dotted vessels [3,4,5,6] and spermatozoa-like vascular structures [3,4,5]. In our cohort, both dotted and linear vessels were noted, and they were indicative of an active disease process. Background color in MF is red, yellow-orange [5] or a mix of the two colors [2]. The primary red or orange back- ground color, changing to skin-colored or light brown in the case of healing of the lesions was also noted in our patients. The presence of scale seems to be not specific in the dermoscopy of mycosis fungoides. The large variation in descriptions of its presence and distribution [2,4,6] may be due to the use of a dermoscope with non-polarized light re- quiring immersion vs. polarized light, where scale is more easily visualized [2]. In our group, scaling was reported in active lesions. Other noted structures such as white diffuse structureless areas, brown lines and globules were present irrespective of disease status. Figure 1. Patient 1, the skin of the left hand in the course of mycosis fungoides before allogeneic stem cell transplantation (alloHSCT). (A) Clinical image of skin lesions: numerous juicy red indurated areas covering >80% of the body surface with a tendency to create crusts can be seen. (B) Dermoscopy: yellow and white scale on juicy red and salmon background is evident. What is more, numerous dotted vessels in unspecific distribution can be seen. Figure 2. Day +696 after alloHSCT. (A) Clinical image: Full healing of lesions in the course of MF. (B) Dermoscopy: on skin-colored back- ground multiple light brown lines are distributed in unspecific arrangement, creating light brown discolorations, no scale. 4 Research Letter | Dermatol Pract Concept. 2023;13(1):e2023047 2. Bilgic S.A., Cicek D., Demir B. Dermoscopy in differential diagnosis of inflammatory dermatoses and mycosis fungoi- des. Int J Dermatol. 2020, 59(7), 843-850. doi: 10.1111/ijd .14925.3. 3. Bosseila M., Sayed Sayed K., El-Din Sayed S.S., Abd El Monaem N.A. Evaluation of Angiogenesis in Early Mycosis Fungoides Patients: Dermoscopic and Immunohistochemical Study.  Dermatology. 2015, 231(1), 82-86. doi:10.1159/0003 82124 4. Lallas A., Apalla Z., Lefaki I., et al. Dermoscopy of early stage mycosis fungoides. J Eur Acad Dermatology Venereol. 2013, 27(5), 617-621. doi:10.1111/j.1468-3083.2012.04499.x 5. Bombonato C., Pampena R., Lallas A., Giovanni P., Longo C. Dermoscopy of Lymphomas and Pseudolymphomas. Dermatol Clin. 2018, 36(4), 377-388. doi:10.1016/j.det.2018.05.005 6. Errichetti E., Apalla Z., Lallas A, et al. Dermoscopic spectrum of mycosis fungoides: a retrospective observational study by the In- ternational Dermoscopy Society. J Eur Acad Dermatol Venereol. 2022, 36(7), 1045-1053. doi: 10.111/jdv.18078 Conclusion Our report adds to the information about the dermoscopic characteristics of MF lesions and their evolution. Observa- tions in the case of disease remission included a change of the background color from initial red-orange to skin-colored or light brown and the disappearance of numerous dotted and linear vessels, while the persistence of vessels was indicative of progressive disease. References 1. Trautinger F., Eder J., Assaf C., et al. European Organisation for Research and Treatment of Cancer consensus recommenda- tions for the treatment of mycosis fungoides/Sézary syndrome – Update 2017. Eur J Cancer. 2017, 77, 57-74. doi:10.1016/j .ejca.2017.02.027