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Chapter 118: Pseudolymphoma

Kathryn Leonard; Bo Wang; Jennifer Mancuso

PSEUDOLYMPHOMA

Therapeutic Approach

Pseudolymphoma is a benign cutaneous lymphoproliferative disorder that occurs in response to many stimuli, including arthropod bites, medications (especially anticonvulsants), infections, vaccinations, contact allergens, tattoos, etc. Diagnosis generally requires clinicopathological correlation. When possible, therapy should involve addressing the causative factor with trigger avoidance or treatment of an underlying infection. Multiple local, systemic, and procedural therapies for all etiologies of pseudolymphoma have been reported. See Table 118-1.

Table 118-1Pseudolymphoma Treatment Table
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Table 118-1 Pseudolymphoma Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical/Intralesional Therapy
Topical corticosteroids   Anti-inflammatory

Clobetasol propionate 0.05% BID

Betamethasone diproprionate 0.05% BID

 Atrophy, hypopigmentation, telangiectasias, striae, tachyphylaxis None IV1,2
Intralesional triamcinolone   Anti-inflammatory 5-40 mg/mL Atrophy, hypopigmentation None IV3
Calcineurin inhibitors   Anti-inflammatory Tacrolimus 0.1% BID Irritation, HSV/VZV infection, skin cancer and lymphoma None IV4
Imiquimod   Immunomodulatory 5% cream 5× weekly for 6 wk Irritation, flu-like symptoms None IV5
Intralesional interferon-α-2A   Anti-proliferative, anti-inflammatory 0.2-0.3 MIU q2wk for 10 wk Flu-like symptoms, injection site reactions None IV6
Intralesional rituximab CD20+ pseudolymphoma Anti-proliferative, anti-inflammatory 10 mg/mL weekly for 18 wk Flushing, pain at injection site Not well defined; consider CBC baseline and 4 wk after treatment IV7
Systemic Therapy
Corticosteroids   Anti-inflammatory Prednisone 40 mg daily, taper over 4 wk Hyperglycemia, hypertension, osteoporosis Blood pressure, HbA1c, DEXA (if long-term use) IV8,9
Antiretroviral HIV-associated Antiviral NA NA NA IV10
Amoxicillin Borrelial lymphocytoma Antimicrobial 500 mg TID × 14-21 d GI upset None IV11,12
Doxycycline Borrelial lymphocytoma Antimicrobial 100 mg BID × 10-21 d GI upset, photosensitivity, avoid in pregnancy None IV9,11,12
Penicillin G Syphilis-associated Antimicrobial 2.4 MIU IM weekly ×3 wk Injection site reactions, Jarisch-Herxheimer reaction None IV13
Hydroxychloroquine   Anti-inflammatory 200-400 mg daily GI upset, cytopenia, photosensitivity, retinopathy CBC, CMP (monthly for 3 mo, then q6mo); retinal exams (baseline and yearly after 5 y if low risk) IV14,15
Methotrexate With preexisting morphea Anti-inflammatory 25 mg weekly GI upset, hepatotoxicity, cytopenia, pulmonary toxicity CBC, CMP (weekly until goal dose, monthly for 3 mo, then q3mo); liver fibroscan (cumulative dose of 3.5 g if no other risk factors) IV16
Mycophenolate mofetil   Anti-inflammatory 500-1000 mg BID GI upset, cytopenia, infection, malignancy CBC, CMP (weekly for 1 mo, monthly for 3 mo, then q3mo) IV17
Thalidomide   Anti-inflammatory 50-100 mg daily Neuropathy, venous thromboembolism, teratogenicity Pregnancy test (weekly ×4 wk, then monthly); CBC, LFT, TSH (monthly); nerve conduction tests (baseline, q6mo ×2, then yearly) IV18,19
Interferon α-2b   Antiproliferative, anti-inflammatory 3 MIU SQ 3× weekly tapered to 1 MIU SQ 3× weekly Flu-like symptoms, injection site reactions, anaphylaxis Not well defined: Consider CBC, CMP, TSH (monthly) IV20
Procedural Therapy
Q-switched Nd:YAG ...

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