10.5826/dpc.1202a91
Introduction: Mycosis fungoides (MF), the most prevalent form of cutaneous T-cell lymphoma (CTCL), has been associated with a variety of environmental and occupational exposures. Flame-retardant clothing (FRC), in contrast to flame-resistant clothing, is chemically treated and may constitute a previously unrecognized occupational hazard.Objectives: To report an association between FRC and MF.Methods: After encountering several young male patients whose onset of MF coincided with the occupational use of FRC and occupation as fire fighters, we did a retrospective search. Additional biopsy proven MF patients with use of FRC were identified by the EPIC electronic medical record using the search terms “CTCL, mycosis fungoides, flame, and flame-retardant.”Results: Eight MF patients, all males, ranging in age from 31 years to 64 years (median age, 35 years) with exposure to FRC were identified. MF remission was noted in three patients who discontinued FRC use and in one patient who used a cotton undershirt barrier, while disease persistence was noted in one patient who continued to use FRC.Conclusions: FRC appears to be associated with development of MF through chronic antigen stimulation. Use of FRC is an occupational hazard for fire fighters. Any patient whose MF coincides with use of FRC should avoid further exposure through avoidance or switching to clothing made from inherently flame-resistant fibers.
text/xml
2160-9381
2021
en
Madeleine Duvic
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
occupational-related exposure
Association of Flame-Retardant Clothing with Mycosis Fungoides: A Retrospective Analysis
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-05-02
2021-09-08
2022-05-02
2022-05-24
e2022091
Dermatol Pract Concept
Introduction: Mycosis fungoides (MF), the most prevalent form of cutaneous T-cell lymphoma (CTCL), has been associated with a variety of environmental and occupational exposures. Flame-retardant clothing (FRC), in contrast to flame-resistant clothing, is chemically treated and may constitute a previously unrecognized occupational hazard.Objectives: To report an association between FRC and MF.Methods: After encountering several young male patients whose onset of MF coincided with the occupational use of FRC and occupation as fire fighters, we did a retrospective search. Additional biopsy proven MF patients with use of FRC were identified by the EPIC electronic medical record using the search terms “CTCL, mycosis fungoides, flame, and flame-retardant.”Results: Eight MF patients, all males, ranging in age from 31 years to 64 years (median age, 35 years) with exposure to FRC were identified. MF remission was noted in three patients who discontinued FRC use and in one patient who used a cotton undershirt barrier, while disease persistence was noted in one patient who continued to use FRC.Conclusions: FRC appears to be associated with development of MF through chronic antigen stimulation. Use of FRC is an occupational hazard for fire fighters. Any patient whose MF coincides with use of FRC should avoid further exposure through avoidance or switching to clothing made from inherently flame-resistant fibers.
Madeleine Duvic
2022/05/02
10.5826/dpc.1202a91
e2022091
Department of Dermatology, University of Texas, MD Anderson Cancer Center
2160-9381
occupational-related exposure
en
e2022091
Effects of Laundering | DuPontTM Nomex® TA Newsletter Volume 1 [Internet]. [cited 2021 Aug 26]. Available from: https://safety.dupont.com/LP=6862. Accessed on 26 August 2021.
Association of Flame-Retardant Clothing with Mycosis Fungoides: A Retrospective Analysis
https://dpcj.org/index.php/dpc/article/download/2021/1556
                    Dermatology Practical & Conceptual


        Association of Flame-Retardant Clothing With
        Mycosis Fungoides: A Retrospective Analysis
   Katherine E. Park1, Vignesh Ramachandran2, Jessica Tran3, Tejas P. Joshi4, Naveen Garg5,
                                    Madeleine Duvic3


1 Department of Dermatology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
2 Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
3 Department of Dermatology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
4 School of Medicine, Baylor College of Medicine, Houston, Texas, USA
5 Department of Radiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA



Key words: mycosis fungoides, cutaneous T-cell lymphoma, flame-retardant clothing, flame-retardant chemicals, occupational-related
exposure
Citation: Park KE, Ramachandran V, Tran J, Joshi TP, Garg N. Association of Flame-Retardant Clothing with Mycosis Fungoides: A
Retrospective Analysis. Dermatol Pract Concept. 2022;12(2):e2022091. DOI: https://doi.org/10.5826/dpc.1202a91
Accepted: October 21, 2021; Published: April 2022
Copyright: ©2022 Park KE 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: Tejas P. Joshi, BS School of Medicine Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA.
E-mail: tejas.joshi@bcm.edu




  ABSTRACT             Introduction: Mycosis fungoides (MF), the most prevalent form of cutaneous T-cell lymphoma
                       (CTCL), has been associated with a variety of environmental and occupational exposures. Flame-re-
                       tardant clothing (FRC), in contrast to flame-resistant clothing, is chemically treated and may constitute
                       a previously unrecognized occupational hazard.
                       Objectives: To report an association between FRC and MF.
                       Methods: After encountering several young male patients whose onset of MF coincided with the oc-
                       cupational use of FRC and occupation as fire fighters, we did a retrospective search. Additional biopsy
                       proven MF patients with use of FRC were identified by the EPIC electronic medical record using the
                       search terms “CTCL, mycosis fungoides, flame, and flame-retardant.”
                       Results: Eight MF patients, all males, ranging in age from 31 years to 64 years (median age, 35 years)
                       with exposure to FRC were identified. MF remission was noted in three patients who discontinued
                       FRC use and in one patient who used a cotton undershirt barrier, while disease persistence was noted
                       in one patient who continued to use FRC.
                       Conclusions: FRC appears to be associated with development of MF through chronic antigen stimu-
                       lation. Use of FRC is an occupational hazard for fire fighters. Any patient whose MF coincides with
                       use of FRC should avoid further exposure through avoidance or switching to clothing made from
                       inherently flame-resistant fibers.




Original Article | Dermatol Pract Concept. 2022;12(2):e2022091                                                                       1
Introduction                                                    Methods
Mycosis fungoides (MF), the most common form of cuta-           A retrospective chart review approved by the MD Anderson
neous T-cell lymphoma (CTCL), is characterized initially by     Institutional Review Board was performed by Dr. Naveen
eczematous skin lesions containing clonal epidermotropic        Garg at the University of Texas MD Anderson Cancer Center
memory CD4+ T-cells [1]. Tan et al first suggested that MF is   (MDACC) to identify and investigate MF patients with a his-
a disease of “chronic antigen stimulation” but the “antigen”    tory of exposure to FRC. All patients were seen by a CTCL
is unknown [2]. Our finding of significant HLA-DR5 and          expert dermatologist (Dr. Duvic) between May 1, 2009 and
DQ-301 associations with MF also supports the possibility       May 31, 2019. Inclusion criteria for this study were a patient
of antigen restriction [3] (MF. As in other non-Hodgkin lym-    age of 18 years or older, biopsy-proven MF confirmed by
phomas, increased rates of MF have also been reported in        expert CTCL dermatopathologists at MDACC, and current/
association with occupational exposures to Agent Orange,        prior exposure to FRC. Patients with use of FRC were iden-
aromatic hydrocarbons, and pesticides [4,5]. There have         tified by searching the EPIC electronic medical record using
also been several reports of non-random clustering of MF,       the Garg Lab search method to create the study population
which further implicate possible environmental or occupa-       [17]. Search terms included “CTCL, mycosis fungoides,
tional exposure as triggers for MF [6–8]. Moreover, we have     flame, and flame-retardant.” Eight patients met the inclusion
demonstrated the presence of geographic hot spots in Texas,     criteria. Descriptive and demographic data were collected
a finding consistent with the hypothesis that MF is triggered   for each patient including demographics (age and sex), stage
by particular exposures [9,10].                                 at presentation, location of skin involvement, treatment his-
    If occupation-related exposure is associated with in-       tory, response to treatment, and length of follow-up.
creased MF risk, then it may result from chronic antigenic
exposure to skin and inherent immune system-altering
                                                                Results
properties of the compounds [11]. Occupations previously
reported to be associated with MF include painters, fire        We identified 8 patients with MF who had worn FRC (Table 1).
fighters, the military, and oil and chemical plant workers,     All patients were men and ranged in age from 31 to 64 years
which require specific workplace attire such as flame-re-       (median, 35 years). We were unable to determine the exact
tardant clothing (FRC). Unlike flame-resistant clothing         brand of FRC used in 7 patients, although 1 patient (case #2)
which is made of inherently flame-resistant fibers, FRC         recalled having used “Bulwark” brand FRC. Three patients
is chemically treated and may be worn against the skin.         were diagnosed with stage IA MF, 3 with stage IB MF, 1 with
While the specific chemicals used vary by manufacturers,        stage IIB MF, and 1 with stage IIIB MF (erythroderma with
historically these have included compounds such as bromi-       blood involvement). Body surface area involvement ranged
nated and chlorinated flame-retardants, as well as formal-      from 0.25% to 97% (median, 18.95%). In 4 patients, we
dehyde-based flame-retardants [12]. Many flame-retardant        were able to ascertain the period of FRC use preceding lesion
chemicals have been banned or voluntarily withdrawn from        appearance: 2 patients (cases #2 and #8) had worn FRC for
the market; however, they have been replaced with other         2 years prior to development of MF; the other 2 patients had
brominated flame retardants. Previous studies have shown        worn FRC for 3(case #1) and 4 (case #4) years before devel-
brominated and chlorinated flame retardants to be asso-         oping MF. The sequential nature of MF onset after a median
ciated with adverse health effects, including reproductive      of 2.5 years of starting FRC use is suggestive of a causal link
toxicity, neurologic impairment, hormonal disturbances,         between MF and cutaneous exposure to FRC. Unfortunately,
and cancer [13–15]. The Epilymph study, a multicenter           we were unable to assess the exact duration of FRC use prior
case-control study, demonstrated a significantly increased      to MF development in any of the remaining four patients.
risk of mature B-cell lymphomas in patients exposed to bro-        Three patients (cases #1, 2 and 4) who discontinued use
minated flame retardants [16].                                  of FRC achieved near complete remission of MF with only
                                                                minimal adjunctive treatment (natural UVB and topical tri-

Objectives                                                      amcinolone); 1 patient witnessed partial MF resolution after
                                                                discontinuing FRC and complete regression following radia-
After encountering 3 young males who presented with early       tion therapy. One patient (case #5), who continued to wear
MF lesions in areas where their skin was chronically ex-        FRC required by his job, had complete remission of his MF
posed to FRC, we performed a retrospective search. We           by using a cotton undershirt barrier. One patient (case #3)
report a case series of 8 patients who used FRC prior to        continued to wear FRC without any barrier and has per-
developing MF and whose MF improved when FRC was no             sistent disease. The remission of disease in patients who dis-
longer worn.                                                    continued FRC, and the persistence of malignancy in the 1



2                                                                   Original Article | Dermatol Pract Concept. 2022;12(2):e2022091
      Table 1. Mycosis Fungoides patients with a history of exposure to flame-retardant chemicals
                                                                  Initial
 Case     Age,                                    Rash            Stage/      Topical       Other     Cessation
 No.      Sex                HPI                Location           BSA        steroid   Interventions  of FRC   Follow-up
 1       31, M    3 yr history of pink to     Popliteal          IB/18.95%   Y          NS              Y             6 mo
                  light brown patches         fossa, hips,
                  beginning after             flanks, and
                  starting work at an oil     groin
                  refinery where he used
                  FRC
 2       48, M    2 yr history of             Arms, lower IA/4.5%            Y          NB-UVB          Y             1 yr
                  hypopigmented               abdomen,
                  patches starting 2 yrs      thighs
                  after beginning to
                  wear Bulwark FRC
 3       35, M    Hyper- and                  Axilla, hips,      IB/15%      Y          NS              N             1.5 yrs
                  hypopigmented               thighs,
                  patches with atrophy        buttocks
                  and telangiectasias of
                  unknown duration
                  recently diagnosed as
                  MF; current FRC use
 4       31, M    4 yr history of             Thigh              IA/0.25%    Y          UV-B            Y             2 yr
                  erythematous scaly
                  patch located where
                  flame-retardant
                  harness rubbed
 5       47, M    10 yr history of            Scalp, arms,       IB/54%      Y          PUVA, topical   Cotton        13 yrs
                  “psoriasis,” 4 yr           trunk, legs                               nitrogen        undershirt
                  history of exposure                                                   mustard         barrier
                  to flame retardant
                  clothing; wears cotton
                  undershirt after
                  previous urticarial
                  reaction to FRC
 6       35, M    History of flame-           Dorsal feet        IA/%        Unknown    PUVA            Unknown       6 mos at
                  retardant exposure                             unknown                                              OSH
                  since age 18 with
                  erythematous patches
                  diagnosed as MF at
                  OSH; presented with
                  unrelated rash
 7       64, M    4 yr history of             Generalized        IIIB/97%    Y          ECP,            Unknown       5 mo
                  erythematous patches                                                  Bexarotene
                  with desquamation                                                     225 mg
                  initially on lower
                  legs with previous
                  exposure to FRC
 8       35, M    10 yr history of            Head,              IIB/48%     Y          TSEB;           Y             3 mo
                  erythematous patches,       trunk, and                                bexarotene
                  plaques, and tumors         extremities                               300 mg
                  that began 2 yrs after
                  starting job with
                  exposure to FRC and
                  gamma-radiation
BSA = body surface area; FRC = Flame-retardant clothing; M = male; N = no; No = number; NS = natural sunlight; ECP = Extracorporeal
photopheresis; TSEB = total skin electron beam; PUVA = psoralen + ultraviolet A; NB-UVB = narrow band ultraviolet B; OSH = outside
hospital; Y = yes; yr = year.



Original Article | Dermatol Pract Concept. 2022;12(2):e2022091                                                                   3
patient who continued FRC use, further implicate FRC as the     fibers. Newer inherently flame-resistant clothing alternatives
trigger for MF induction.                                       use next-generation polymers and fibers rather than chemi-
    While we are unable to exclude the possibility that other   cal flame-retardants. Additionally, unlike FRC, clothing from
factors (eg environmental and occupational exposures inde-      inherently flame-resistant fibers does not lose efficacy with
pendent of FRC use) could have also initiated MF in our         repeated washes [21], and therefore represents both a safer
patients, the distribution of lesions in sun shielded areas     and more economical option compared to FRC.
in most of our patients is also consistent with FRC use (al-
though it should be noted that presentation of MF lesions
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Original Article | Dermatol Pract Concept. 2022;12(2):e2022091                                                                              5
