What is responsible for this man’s pruritic eruption?

A 59-year-old male presented with a complicated medical history. He has a 2-year history of abdominal pain with partial gastrectomy and cholestectomy for benign inflammatory processes over a year ago. He was treated with systemic corticosteroids for 15 months before he was able to be weaned off. 

He presents today with a pruritic eruption on his trunk and proximal extremities of a few months duration that started 2 to 3 months prior, before he was completely off the prednisone. 

What is responsible for the pruritic eruption?

A. Follicular eczema

B. Fatty acid deficiency from malabsorption from GI surgeries

C. Asteatotic eczema from bathing habits

D. Cutaneous T-cell lymphoma

E. Contact dermatitis

(Answer and discussion on next page)

Answer: Cutaneous T-cell lymphoma

It took several biopsies over a 4-month period and the workups confirmed a diagnosis of early stage cutaneous T-cell lymphoma. He was placed on light treatment (ultraviolet B therapy) and the results were a complete remission, which was maintained 1 year later.

Follicular eczema would be unusual this late an onset. Asteatoses is more likely but he did not respond to conventional treatment and his history did not suggest it as a cause. Fat malabsorption is seen colectomy when the bile salts cannot be reabsorbed, unlike what is seen here. Follicular pattern this widespread would be an unusual pattern for contact dermatitis.