Cutaneous Hodgki11's disease 
Case report 
CUT ANEOUS HODGKIN'S DISEASE 
G. Torlone, K. Peris, G. Mazzocchetti, E. Caracciolo, I. Schmidt and S. Chimenti 
ABSTRACT 
A 40-year-old man presented with a one year history of erythematous papules and nodules on the trunk and in the right axilla. 
Three years earlier, a diagnosis of stage I Hodgkin's disease had been established. Complete remission was achieved following 
4 cycles of ABVD (doxorubicin, bleomicin, vinblastine, dacarbazine) combination therapy. Histologic examination of a skin 
biopsy specimen showed the presence of a diffuse, dense infiltrate throughout the whole dermis to the subcutaneous tissue. The 
infiltrate was composed of small lymphocytes, eosinophils, plasmacells and Reed-Sternberg cells. Immunohistochemistry 
revealed the positivity of neoplastic cells for BerH2 (CD30) and LeuMl (CD15) antibodies. Reactivity of small lymphocytes 
for UCHLl (CD45RO) was also observed. Routine laboratory examinations were within normal Iimits. Bone marrow biopsy and 
instrumenta! investigations (chest X-ray, computed tomographic seans of abdomen and pelvis) showed no abn01malities. The 
presence ofEpstein-Barrviral (EBV) genome was analysed by polymerase chainreaction (PCR) technique. EBV DNA, however, 
was not found. Based on histologic and immunohistochemical findings, a diagnosis of secondary cutaneous Hodgkin's disease 
wasmade. 
KEYWORDS 
Hodgkin's disease - specific skin lesions 
INTRODUCTION 
Hodgkin's disease (HD) is amalignant I ymphoproliferative 
disorder histologically characterized by dense, mixed infiltrate 
of small T lymphocytes, histiocytes, plasmacells and 
acta dernwtovenerologica AP A. Vol 2. 93, No 4 
eosinophils, and typical Reed-Stemberg cells ( 1 ). Cutaneous 
involvement in systemic HD may be either non-specific or 
specific. Non-specific skin manifestations include pruritus, 
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purpura. urticaria, exfoliative dermatitis, bullous lesions and 
herpes zoster. Specific skin lesions are far less common and 
may appear as plaques, papules, nodules, tumours or 
erythroderma, alone or in combination (2). We describe a 
case of cutaneous Hodgkin's disease in a 40-year-old man in 
whom nodal HD had been diagnosed and treated three years 
earlier. 
CASEREPORT 
A 40-year-old man presented with one-year history of 
persistent, erythematous papules and nodules, 0.5-3 cm in 
diameter, scattered on the trunk and in the right axilla (Fig. 
1,2). Physical examination failed to reveal any lymph node 
Fig. l. A 40-year-old man with papules and nodules on the 
trunk. 
involvement. Histologic examination of a skin biopsy 
specimen showed a diffuse, dense dermal infiltrate extending 
into the subcutaneous tissue (Fig. 3). The infiltrate was 
116 
composed of small lymphocytes, histiocytes, eosinophils 
and multiple atypical large cells with prominent, basophilic 
nucleoli (Reed-Sternberg cells) (Fig. 4). Immuno-
histochemical investigations, perfo1med with a standard 3-
steps immunoperoxidase technique on routinely fixed, 
paraffin-embedded tissue sections, demonstrated the positivity 
ofneoplastic cells for BerH2 (CD30) and LeuMl (CD15) 
Fig. 2. A reddish plaque in the right axilla. 
antibodies. Positivity for LN2 (CD74), KPl (CD68) and 
UCHLl (CD45RO) was also found. Negative reaction was 
observed with B lymphocytes associatedmarker such as L26 
(CD20). The presence of Epstein Barr vira! (EBV) genome 
has been evaluated by polymerase chain reaction (PCR) 
technique on formalin fixed, paraffin-embedded tissue 
sections employing oligonucleotide primers that bracket IRl 
and IR3 regions. EVB-infected celi line P3T was used as 
positive control; normal kidney and placenta with no clinical, 
serologic or morphologic signs ofEBV infection were used 
as negative controls. Samples containing all PCR reagents 
with the exception of target DNA were also used as negative 
controls. EBV DNA was not found in our specimen. 
Three years earlier, stage I HD had been diagnosed on iliac 
lymphnodes.Histology showedfeatures ofnodular sclerosing 
subtype according to the Rye-classification. The patient had 
beensuccessfullytreated with4cyclesof ABVD (doxorubicin, 
bleomicin, vinblastine, dacarbazine) combination therapy. 
The staging work-up of the patient, during our observation, 
revealed either normal or negative results for the following: 
routine laboratory examinations, bone marrow biopsy, chest 
X-ray, CT seans of the abdomen and pelvis. Based on 
patient's clinical history and histologic and immuno-
histochemical findings, a diagnosis of secondary cutaneous 
Hodgkin's disease was established. The patient has been 
treated with PROMACE/CytaBOM combination therapy. 
acta dennatovenerologica A.P.A. \!o/ 2, 93, No 4 
Fig. 3. Scanning magnification shows a dense, diffuse infiltrate through the whole de1mis to the subcutaneous tissue (H/E, 25x) 
Fig. 4. Higher magnification reveals typical Reed-Stemberg 
cells (H/E, 400x) 
acta dermatovenerologica AP A. Vol 2, 93, No 4 
Complete remission was achieved after 6 cycles. After a 
follow-upperiodofoneyear,norecurrencehasbeenobserved. 
DISCUSSION 
The first case of specific cutaneous lesions of HD has been 
already described in 1906 by Grosz (3). The patient was a 21-
year-old man with lymphoadenopathy and skin nodules, 
some of which were ulcerated. Histology revealed 
"lymphogranulomatoid tissue and Reed-Sternberg cells" in 
both specimens. Since that tirne, severa! other cases of 
specific cutaneous involvement in HD have been reported. 
The incidence varies from 0.5 % to 7.5 % (4). Reddish 
papules and nodules located on the trunk are the most 
cornmon clinical aspect. They usually occur in advanced 
stage of the disease and are associated with a poor prognosis 
(5) . Our patient, however, had a history oflirnited disease and 
no evidence of systernic involvement at the tirne of our 
observation. The histology of skin lesions in HD can be 
classified according to the R ye classification ( 6). In our case, 
the nodular sclerosing subtype had been previously 
demonstrated on the iliac lymph nodes. 
The immunophenotipic pattem can be useful in the diagnosis 
of cutaneousHD (6). Particularly, BerH2 (CD30) andLeuMl 
(CD15)recognizeReed-Stembergcells whereas KPl (CD68) 
and LN2 (CD74) react with rnonocytes, macrophages and 
histiocytes respectively. Small lymphocytes can be CD4 or 
rarely CD8 positive. In this contest it should be mentioned 
that most reported cases had been rnisdiagnosed such as 
mycosis fungoides and lymphomatoid papulosis (1). 
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Primary cutaneous HD has been described but its reai 
existence is stili controversial (7,8). Silverman et al. (7) 
suggested that one must find a skin infiltrate consistent with 
HD and no demonstrable nodal involvement for at least three 
months after development of the skin lesions. However, 
following the literature, most of the reported cases, as our 
patient, represented secondary cutaneous HD (2,4-6). 
Recently, the monoclonal form of Epstein-Barr viral 
genome has been demonstrated in some cases of nodal HD 
using molecular analysis (9-11 ). This finding suggests that 
EB V mayplay anetiopathogeneticrole atleastin aproportion 
ofHD. In our patient, however, EBV DNA was not detected 
by PCR. 
Treatment of cutaneous HD does not differ from that used 
for the nodal counterpart. In our case, local electron beam 
radiation therapy could not be performed because of the deep 
cutaneous involvement whereas PROMACE/Cyta BOM 
combination therapy was successfully employed. 
In conclusion, an unusual case of secondary cutaneous 
Hodgkin's disease has been described in which the patient 
had had lirnited HD of iliac lymph nodes three years before. 
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AUTHORS' ADDRESSES 
118 
Giancarlo Torlone M.D., Department of Dermatology, 
University ofL'Aquila, Via Vetoio, 67010 Coppito, L'Aquila, Italy 
Kety Peris M.D., same address 
Giampiero Mazzocchetti M.D., same address 
Ernesta Caracciolo M .D., same address 
Iris Schmidt M.D., same address 
Sergio Chimenti, M.D., professor and chairman, san1e address 
acta dermatovenerologica A.P.A. \/o/ 2, 93, No 4