Mycosis Fungoides: a Dermatological Masquerader D

REVIEW ARTICLE DOI 10.1111/j.1365-2133.2006.07526.x Mycosis fungoides: a dermatological masquerader D. Nashan, D. Faulhaber,* S. Sta¨nder,* T.A. Luger* and R. Stadler Department of Dermatology, University of Freiburg, Hautstr. 7, 79104 Freiburg, Germany *Department of Dermatology, University of Mu¨nster, Mu¨nster, Germany Department of Dermatology, Klinikum Minden, Minden, Germany

Summary

Correspondence Mycosis fungoides (MF), a low-grade lymphoproliferative disorder, is the most D. Nashan. common type of cutaneous T-cell lymphoma. Typically, neoplastic T cells localize E-mail: [email protected] to the skin and produce patches, plaques, tumours or erythroderma. Diagnosis of MF can be difficult due to highly variable presentations and the sometimes non- Accepted for publication 8 June 2006 specific nature of histological findings. Molecular biology has improved the diagnostic accuracy. Nevertheless, clinical experience is of substantial importance as Key words MF can resemble a wide variety of skin diseases. We performed a literature clinical subtypes, differential diagnoses, mycosis review and found that MF can mimic >50 different clinical entities. We present fungoides, overview a structured framework of clinical variations of classical, unusual and distinct Conflicts of interest forms of MF. Distinct subforms such as ichthyotic MF, adnexotropic (including None declared. syringotropic and folliculotropic) MF, MF with follicular mucinosis, granulomatous MF with granulomatous slack skin and papuloerythroderma of Ofuji are delineated in more detail.

Mycosis fungoides (MF), a low-grade lymphoproliferative dis- fungoides’ with ‘differential diagnosis’ and ‘clinical picture’, order, is the most common type of cutaneous T-cell lymph- and ‘mycosis fungoides’ and ‘cutaneous T-cell lymphoma’ in oma. Typically, neoplastic T cells localize to the skin and conjunction with clinically descriptive adjectives. From extrac- produce patches, plaques, tumours or erythroderma. Diagnosis ted articles the related articles and publishing authors were of MF can be difficult due to highly variable presentations and also screened. Further original articles were extracted from ref- the sometimes nonspecific nature of histological findings. erence lists. Molecular biology has improved the diagnostic accuracy. Nev- We thereby present a review of all currently published clin- ertheless, clinical experience is of substantial importance as ical pictures of MF simulating other dermatoses and distinctive MF can resemble a wide variety of skin diseases. clinicopathological features which are in part considered sep- Diagnosis of MF is based on a combination of clinical pre- arately in the new World Health Organization (WHO)—Euro- sentation, histopathology and gene rearrangement.1 None of pean Organization for Research and Treatment of Cancer these factors exclusively determines the diagnosis. Histologi- (EORTC) classification.6 The illustration of MF variants follows cally, MF is characterized by the presence of large atypical in Tables according to clinical signs and under the headings of lymphocytes, a lymphocytic infiltrate in the papillary dermis more distinct subtypes. and thickened collagen fibres. However, in early MF not all of these pathological findings are present and distinction from an 2 Clinically and morphologically unusual inflammatory infiltrate is often difficult. Detection of a mono- variations of mycosis fungoides clonal T-cell infiltrate is not lymphoma specific. Positive poly- merase chain reaction (PCR) results are also found in diseases In early stages of MF (T1N0M0 or T2N0M0) characteristic le- such as psoriasis, pityriasis lichenoides et varioliformis acuta sions consist of erythematous macules or papules, which are (PLEVA) and lichen ruber.3,4 Thus clinical presentation is a primarily superficial and resemble an ‘eczema’ with sharply major factor determining the diagnosis.5 defined borders. Often some degree of scaling is observed, similar to psoriasis. The edges of the lesions might exhibit in- Search criteria creased scaling, corresponding to a growing infiltrate. The configuration can be arciform, annular, semiannular, serpingi- This article emerged from Medline searches, manual searches nous or polycyclic.7 The skin surface can be atrophic, exhibit- in dermatological journals and textbooks, and from personal ing wrinkles. The colour can be orange to bright red or experiences. Electronic key word searches included ‘mycosis can present livid or brown-red components. Spontaneous

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Table 1 Differential diagnoses of classical mycosis fungoides (MF) are The descriptive term ‘mycosis fungoides’, chosen in 1806 assembled based on a predominant clinical sign. A representative by Alibert, already suggests the first differential diagnosis of publication with a clinically imitative MF is given for each differential tinea corporis for a typical MF lesion. The coincidence of der- diagnosis matophyte infections and MF has been described.9,10 Further descriptive terms provide hints for the differential diagnosis: Clinical sign Differential diagnosis First author lichenification, lichenoid, eczematous, seborrhoeic, urticarial, Eczematous Seborrhoeic eczema Figure 1 erythematous, hypopigmented, pityriasis-like.11 Thus the dif- 82 Perioral dermatitis Wolf 1992 ferential diagnosis includes nonspecific eczema, nummular Palmoplantar eczema Spieth 200219 eczema, seborrhoeic eczema, contact dermatitis, atopic derma- Dyshidrotic eczema Kempf 200580 Contact dermatitis Spieth 200219 titis, psoriasis, drug reaction, lichen simplex chronicus and 12,13 Atopic eczema Kazakov 200412 lichen planus (Table 1). Scaling Psoriasis Zackheim 200283 Limited involvement of the skin, especially as unilesional Psoriasis palmaris Spieth 200219 typical MF, is not uncommon.14–17 A well-documented, Psoriasis plantaris Figure 2 although not universally accepted, solitary form is the paget- 84 Parapsoriasis Ackermann 1996 oid reticulosis type Woringer–Kolopp, characterized by a sin- Tinea corporis Chaves 200285 86 gle, scaling and erythematous MF lesion with acral Tinea pedis Resnik 1995 18 Erythematous Erythema multiforme Krebs 197887 localization. A challenge for the clinician might be the Kazakov 200412 appearance of typical MF in an atypical localization, e.g. MF Annular erythema Lim 200388 simulating palmoplantar or periorificial eczema, isolated alope- Cogrel 200589 cia or affecting the mucosa (Figs 1 and 2).19,20 45 Alopecia Alopecia areata Burg 1992 At the tumour stage IIB (T3N0/1M0) nodules of various sizes are found. They can be flat or dome-shaped. Their colour For a further overview publications of Zackheim and McCal- mont13—with 23 differential diagnoses—and Kazakov et al.12 is yellow-red or red-blue to brown. The lesions are more can be recommended. prominent and deeper than plaques. MF tumours mainly develop in the course of the disease or in conjunction with eczematous lesions. The surface is soft on palpation, which regression of lesions can occur; this is sometimes limited to distinguishes the lesions from metastases of solid carcinomas. the centre of the lesion. Alopecia may develop in lesional sites Ulcerations are frequently seen, which can develop secondary or even in clinically unaffected skin. The lesions are asymmet- infections. Tumours develop in either pre-existing MF lesions rically distributed and are predominantly located in a ‘swim- or de novo. The location and configuration of these tumours are suit’ distribution, i.e. preferentially on the abdomen, hips, comparable with B-cell lymphoma. Another tumorous lymph- buttocks and breasts. Lesions are also seen on the medial sides oma and possible differential diagnosis is lymphomatoid papu- of proximal extremities. The mucosa can be affected at any losis (LyP). In 1968, Macaulay21 summarized LyP as a stage of disease.8 It is still under discussion whether parapso- chronically recurring papulonodular dermatosis, sometimes riasis with its scattered finger-like striped lesions on the flanks self-limiting. It can be excluded by its brownish-reddish cen- is an entity on its own or is a precursor of MF. trally necrotic papules, spontaneous healing within weeks and

Fig 1. Mycosis fungoides imitating seborrhoeic eczema.

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Table 3 Differential diagnoses of erythrodermic mycosis fungoides

Clinical sign Differential diagnosis Erythrodermic Se´zary syndrome Adult T-cell leukaemia Actinic reticuloid Atopic dermatitis Drug reaction Psoriasis Age-dependent erythroderma

leukaemic involvement’ describe the difficulty of either delineation. SS was defined by Se´zary and Bouvrain in 193823 as a triad of erythroderma, lymphadenopathy and atypically large mononuclear blood cells. It is clinically associated with leonine facies, ectropion, alopecia of the scalp, palmoplantar hyperkeratosis and fissures and dystrophy of the nails. Similar but less frequent monosymptomatic forms or new phenomena such as a vitiligo-like leucoderma with MF and SS hamper the diagnosis.24–26 A diagnostic discrimination is presented by the Interna- tional Society for Cutaneous Lymphomas, specifying in add- ition to erythrodermic MF and SS, ‘other erythrodermic cutaneous T-cell lymphoma, not otherwise defined’.27 Fur- ther differential diagnoses include primary and secondary erythrodermas caused by psoriasis, atopic dermatitis, drug eruption or age-dependent erythroderma (Table 3). Actinic reticuloid sometimes exacerbates to erythroderma; however, Fig 2. Mycosis fungoides imitating palmoplantar psoriasis. it becomes aggravated in sunlight-exposed skin. It is considered as a form of a cutaneous T-cell pseudolymphoma by most authors.28 Table 2 Differential diagnoses of tumorous mycosis fungoides lesions A real clinical challenge is provided by unusual and newly described variants of MF comprising hyperpigmented, hypopigmented, urticarial, bullous, solely papular, pustular and Clinical sign Differential diagnosis hyperkeratotic variants for which diagnosis is easier in con- Tumorous Lupus erythematosus junction with typical MF lesions or a positive history of MF B-cell lymphoma 29–31 Lymphomatoid papulosis (Table 4). Hypopigmentation and a vitiligo-like outcome CD30+ lymphoma are predominantly described in individuals with dark skin. Hodgkin disease Mainly asymptomatic, irregularly confined, white macules are Sarcoma seen.32,33 A critical review suggested that only 19 of 106 published cases with hypopigmentation were truly MF.34 The bullous form of MF was first described by Kaposi in 1887. Flaccid or tense, often multiple or even generalized blisters a residual stage of hyperpigmented macules or atrophic scars. appear on normal skin or within plaques. A positive Nikolsky Awareness is required as the coexistence of LyP and MF is not sign is observed. Diagnosis is urgent as bullous lesions of MF rare.22 MF tumours have to be differentiated from secondary indicate a poor prognosis.35 lymphomatoid diseases such as CD30+ anaplastic T-cell Some case reports point out single atypical lesions as a clue lymphoma and Hodgkin disease (Table 2). for a false diagnosis, e.g. a warty lesion misdiagnosed as a se- Erythrodermic MF, stage III (T4N0/1M0), is defined by borrhoeic keratosis or Bowen’s disease.36,37 Other clinical erythroderma, a red to red-bluish colour, affecting the whole impressions of atypical MF have stimulated diagnoses such as body surface sometimes sparing small areas of normal skin. purpura pigmentosa, vasculitis and pyoderma gangrenosum Scaling can range from little exfoliation to severe desquama- (Table 5).38 Especially purpuric eruptions are repeatedly de- tion. scribed with petechial patches and varying degrees of epider- The erythroderma of Se´zary syndrome (SS) is closely mal changes—scaling, vesiculation, lichenification—and related. Definitions such as ‘SS preceded by MF’ or ‘MF with brownish pigmentation from haemosiderin accumulation.33

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Table 4 Differential diagnoses of clinical Clinical sign Differential diagnosis First author variants of mycosis fungoides (MF) with a 12 lower incidence than the classical pictures. Hypopigmented Pityriasis versicolor Kazakov 2004 Authors who published MF cases with the Piyriasis alba Whitmore 199491 11 according clinical differential diagnosis are Vitiligo Ardigo 2003 given in column 3. Clinical pictures are 12 Leprosy Kazakov 2004 76 12 published in overviews by Goerdt et al. , Postinﬂammatory hypopigmentation Kazakov 2004 Howard and Smoller90, Zackheim and 92 Hyperpigmented Acanthosis nigricans Willemze 1985 McCalmont13, Kazakov et al.12 and Kotz et al.81 Ashy dermatosis Kazakov 200412 Hypo-hyperpigmented Poikiloderma (vasculare atrophicans) Wain 200593 Bullous/vesicular Bullous autoimmune dermatosis Ho 200094 Pemphigus vulgaris Roenigk 197195 Hyperkeratotic Palmoplantar hyperkeratosis Goldberg 199796 Verrucae vulgaris Goldberg 199796 Keratosis lichenoides chronica Bahadoran 199897 Porokeratosis of Mibelli Breneman 199398 Papular Drug-induced pseudolymphoma Marzano 199914 Lymphomatoid papulosis Kodama 200531 Pustular Palmoplantar pustulosis Moreno 199099 Generalized pustulosis Camisa 1994100 Single lesions Seborrhoeic keratosis Bazza 200236 Bowen’s disease Yoo 200337 Eryipelas Brill 2005101

Table 5 Mycosis fungoides (MF) can imitate more complex Table 6 Distinct subtypes of mycosis fungoides (MF) dermatological disorders which are listed under differential diagnosis. Authors debating these differential diagnoses in conjunction with MF Distinct MF entity First author are named Ichthyotic MF Eisman 2003110 Ku¨tting 199641 Classification Differential diagnosis First author Badawy 200242 Mucous membrane Mucositis Wain 20038 Adnexotropic MF van Doorn 200248 Vessels Lichen aureus, capillaritis Ameen 2000102 Granulomatous MF Goerdt 199676 Pyoderma gangrenosum Ho 200094 Granulomatous slack skin LeBoit 199465 Carbia 200238 von Haselen 1998111 Gangrene Lund 1990103 Topar 2001112 Purpura pigmentosa Barnhill 198833 MF with follicular mucinosis Vollmer 200252 Cather 1998104 Papuloerythroderma of Ofuji Hur 200258 Lymphoma, Actinic reticuloid Neil 198528 Pereiro 200373 leukaemia, Sarcoma Machler 1994105 tumour Others Ischaemic foot Goldstein 1999106 ‘Invisible dermatosis’ Pujol 2000107 Ichthyotic mycosis fungoides 108 Hwong 2001 MF may be mistaken for an ichthyosis. Clinical aspects of an Dissecting cellulitis Gilliam 1997109 ichthyotic MF more often reveal extensive skin involvement of the scalp (Fig. 3).40 Typical dry scaling affects the trunk and extremities. Sometimes a mild erythroderma-like condition may develop.41,42 Clinically obvious follicular keratosis, comedo- like lesions and epidermal cysts are mentioned as additional More definite clinicopathological findings distinguishing cuta- manifestations.40,42 A coexpression of ichthyotic and follicular neous lymphoma from pigmented purpuric dermatosis are MF has been published.43 In MF, in contrast to other lympho- outlined by Martıńez et al.39 mas, the ichthyosis is not paraneoplastic but is self-defining and has a fairly good prognosis.43 Distinct entities of mycosis fungoides Adnexotropic mycosis fungoides More clear-cut features lead to the diagnosis of ichthyotic MF, different adnexotropic forms of MF, granulomatous forms of This is mainly misdiagnosed as acneiform lesions and alopecia. MF, MF with follicular mucinosis and latterly also papulo- Adnexotropic MF can be itemized into subtypes for which dif- erythroderma of Ofuji (Table 6). ferential diagnoses are given (Table 7).

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hyperaesthesia of the affected skin area and anhidrosis are possible adjuncts. Eight of 15 published cases of SLHA were clas- siﬁed as syringotropic cutaneous lymphoma, for which 13 further cases are now known.46 Besides clinical similarities to SLHA, erythema punctata, sometimes with follicular accentu- ation and milia, is described for the syringotropic form. The facial localization is reminiscent of discoid lupus erythematosus. The typical histology shows a dense syringotropic lymphocytic inﬁltrate sometimes surrounding hyperplastic eccrine glands and eccrine ducts. Generally considered a variant of MF, both have a similarly good prognosis.47

Folliculotropic mycosis fungoides

Folliculotropic MF, or follicular MF, is predominantly localized on the head and neck (Fig. 4). Clinically it presents follicular papules (often grouped), alopecia and acneiform lesions.48,49 Patients often complain about severe pruritus.48 Even pseudotumorous forms with nodules have been described, with a marked follicular hyperplasia rather than a lymphocytic proliferation.50 Otherwise perifollicular pleomorphic infiltrates show various degrees of folliculotropism without epidermo- tropism. Follicular MF is sometimes is associated with follicular mucinosis. In 2002, 51 cases of follicular MF were recorded in the Netherlands.48 Diagnostic accuracy and adap- ted therapeutic regimens seem necessary as follicular MF might be less responsive to standard treatment modalities: this is a possible explanation for disease progression in the Dutch collection.6,48,51 Fig 3. Ichthyotic form of mycosis fungoides. Most cases of folliculotropic MF show mucinous degener- ation of the hair follicles and are traditionally designated as MF-associated follicular mucinosis. However, this is not a pre- Syringolymphoid hyperplasia (SLHA) was first described by requisite and, with or without associated follicular mucinosis, Sarkany in 1969.44 Published as lymphomatoid granulomato- these forms are named ‘follicular MF’ or ‘folliculotropic MF’. sis, its characteristics were alopecia, anhidrosis, hypertrophy The difficulty of a diagnostic assignment of follicular mucino- of eccrine glands and vasculitis. In 1992 Burg and Schmo¨c- sis towards MF or of delineation as a primary and exclusive kel45 revealed an association with cutaneous T-cell lymphoma. clinical manifestation is reflected in ongoing discussions.52–57 The clinical presentation is variable, and includes solitary or The differentiation cannot be assisted by PCR of the T-cell re- multiple patches and plaques or skin-coloured to reddish pa- ceptor, as the primary or idiopathic follicular mucinosis might pules, with more extensive skin involvement resembling fol- also exhibit monoclonal T-cell populations. Furthermore, follicular hyperkeratosis, poikiloderma atrophicans vasculare, licular mucinosis has been observed in association with erythroderma and even palmoplantar hyperkeratosis. Hair loss, other MF subforms, such as the adnexotropic form, already

Table 7 Differential diagnoses of adnexotropic forms of mycosis fungoides Clinical sign Differential diagnosis First author Adnexotropic Rosacea Sherertz 1986113 Eczema Bonta 2000114 Seborrhoeic dermatitis van Doorn 200248 Comedones, cysts Oliwiecki 1992115 Epidermal cysts Lacour 1993116 Comedones, cysts, alopecia Peris 1999117 Follicular hyperkeratosis Klempke 199951 Poikiloderma vasculare atrophicans Brecher 2002118 Idiopathic syringolymphoid hyperplasia Kazakov 200412 Discoid lupus erythematosus Thein 200446

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Fig 4. Adnexotropic form of mycosis fungoides.

Fig 5. Mycosis fungoides with granulomatous slack skin. characterized, and papuloerythroderma of Ofuji for which was included in the EORTC64 and then the WHO–EORTC clas- clinical description and differential diagnoses will follow.58 sification6 as a provisional entity. So far up to 42 cases have The coexistence of syringotropic and folliculotropic cutane- been reported. Granulomatous T-cell infiltrates and loss of ous lymphomas also results in acneiform manifestations with elastic fibres lead to asymptomatic skin wrinkles, mainly in follicular papules, comedones, milia, cysts, dry skin and alope- the flexures (Fig. 5).65 Sometimes pruritus and erythema are cia.47 Some authors suggest inclusion of these clinical variants, described. Granulomatous MF may be preceded by erythema- as well as other pilotropic forms of MF, under the term ‘ad- tous scaling patches or macules, and may coexist with classical nexotropic cutaneous lymphomas’.59,60 MF lesions. Benign as well as progressive courses were described. In 50% of cases coexistence with Hodgkin disease or Granulomatous mycosis fungoides and nodal non-Hodgkin disease is observed. granulomatous slack skin From a histological point of view it is discussed whether granulomatous MF and granulomatous slack skin belong Ackerman and Flaxman61 proposed the term ‘granulomatous together.66,67 The pathogenesis of granuloma formation in MF’ in 1970. In 1978 Ackerman62 added the term ‘granulo- lymphoma is unknown and its occurrence is not specific for matous slack skin disease’. In 1968 Bazex et al.63 described a MF. Similar histological formations have been described in clinical form similar to cutis laxa as ‘Besnier–Boeck–Schau- pleomorphic T-cell lymphoma, panniculitis-like T-cell lymph- mann disease’. In 1997 and 2005 ‘granulomatous slack skin’ oma and in B-cell lymphomas.68 A case report of a CD30+

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Table 8 Differential diagnosis of granulomatous forms of mycosis the diagnosis can only be confirmed during the course of dis- fungoides ease.4 Whole-body inspection often allows identification of typical lesions besides atypical lesions, thus guiding towards Clinical sign Differential diagnosis First author the correct diagnosis. Taking all information together and add- Granulomatous Granuloma annulare Jouary 200270 ing histology, differential diagnoses are no longer a problem. Rosacea Sherertz 1986113 Once a lymphoma has been diagnosed a consequent follow- 71 Sarcoidosis Bessis 1996 up is also required to detect possible recurrence or manifest- 119 Necrobiosis Woollons 1999 ation of other associated conditions. Skin atrophy Cutis laxa van Haselen 1998111 We end with a statement by Zackheim and McCalmont13 who called MF ‘the great imitator’. They compared the cha- meleon-like diversity in clinical presentation of MF with the variability of clinical conditions seen in syphilis. lymphoma with granulomatous slack skin exists, so not even granulomatous slack skin is a specific subform of MF.69 There- Acknowledgments fore clinically and histologically granulomatous MF variants have to be differentiated from other cutaneous T-cell lympho- We thank Professor Rein Willemze for revision and constructive mas and from sarcoidosis, granuloma annulare and infectious advice. granulomas (Table 8).70,71 The so-called ‘sarcoidosis–lymphoma syndrome’ includes the association of sarcoidosis and References lymphoma, among other entities described in association with MF.72 1 Willemze R, Meijer CJ. Rationale of a new classification for the group of primary cutaneous lymphomas. Semin Cutan Med Surg 2000; 19:71–7. Papuloerythroderma of Ofuji 2 Naraghi ZS, Seirafi H, Vakikhani M et al. Assessment of histologic criteria in the diagnosis of mycosis fungoides. Int J Dermatol 2003; Is papuloerythroderma of Ofuji no more a differential diagno- 42:45–52. 58,73 sis but a precursor of MF? Papuloerythroderma of Ofuji 3 Dereure O, Levi E, Kadin ME. T-cell clonality in pityriasis li- 74 was first described in 1984. It is characterized by red- chenoides et varioliformis acuta: a heteroduplex analysis of 20 brownish, partly confluent flat papules; the flexors remain cases. Arch Dermatol 2000; 136:1483–6. unaffected, and this is described as a ‘deckchair distribution’. 4 Burg G, Kempf W, Dummer R. Diagnostic signs of cutaneous Reports describe the association of papuloerythroderma of Of- lymphomas. J Eur Acad Dermatol Venereol 2001; 15:358–9. 5 Stadler R. Treatment of cutaneous T cell lymphoma. Skin Pharmacol uji and cutaneous lymphoma as well as the development of a Appl Skin Physiol 2002; 15:139–6. cutaneous lymphoma after primary diagnosis of papuloeryth- 6 Willemze R, Jaffe ES, Burg G et al. WHO–EORTC classification for 75 roderma of Ofuji. Case reports demonstrate the similarity to cutaneous lymphomas. Blood 2005; 105:3768–85. MF with eosinophilia, with elevated serum IgE and similar 7 Saada D, Lami MD, Vabres P et al. Mycosis fungoides presenting histological and molecular biological criteria. as annular erythema. Ann Dermatol Venereol 2005; 132:35–7. 8 Wain EM, Setterfield J, Judge MR et al. Mycosis fungoides involving the oral mucosa in a child. Clin Exp Dermatol 2003; 28:499–501. Distinguishing diagnoses 9 Hubert JN, Callen JP. Recalcitrant tinea corporis as the presenting manifestation of patch-stage mycosis fungoides. Cutis 2003; Based on clinical evaluation, the progress of MF and trans- 71:59–61. formation into other lymphoma subtypes can be assessed. The 10 Capella GL, Altomare GF. Mycosis on mycosis fungoides: zoophi- coexistence of different primary cutaneous lymphomas and lic dermatophytosis selectively superimposed on pre-existing cu- secondary cutaneous lymphomas presents a challenge for dif- taneous T-cell lymphoma (mycosis fungoides) plaques. Mycoses ferential diagnosis.76 Coexisting dermatological conditions 2003; 46:67–70. such as psoriasis or neurofibromatosis and atopic dermatitis 11 Ardigo M, Borroni G, Muscardin L et al. Hypopigmented mycosis fungoides in Caucasian patients: a clinicopathologic study of 7 also have to be taken into account.77–79 Kempf et al. published cases. J Am Acad Dermatol 2003; 49:264–70. a review on paraneoplastic skin reactions including the sign of 12 Kazakov DV, Burg G, Kempf W. Clinicopathological spectrum of 80 Leser–Tre´lat or PLEVA with MF. mycosis fungoides. J Eur Acad Dermatol Venereol 2004; 18:397–415. 13 Zackheim HS, McCalmont TH. Mycosis fungoides: the great imitator. 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