10.5826/dpc.1201a06
text/xml
2160-9381
1719
en
Nicola Di Meo
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
diagnosis
Yellow Plugs: An Additional Dermoscopic Criterion in the Diagnosis of Primary Cutaneous B-Cell Lymphoma
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-02-02
2021-03-14
2022-02-02
2022-02-09
e2022006
Dermatol Pract Concept
Nicola Di Meo
2022/02/02
10.5826/dpc.1201a06
e2022006
Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
2160-9381
diagnosis
en
e2022006
Bombonato C, Pampena R, Lallas A, Giovanni P, Longo C. Dermoscopy of lymphomas and pseudolymphomas. Dermatol Clin. 2018;36(4):377-388. DOI: 10.1016/j.det.2018.05.005. PMID: 30201147.
Yellow Plugs: An Additional Dermoscopic Criterion in the Diagnosis of Primary Cutaneous B-Cell Lymphoma
https://dpcj.org/index.php/dpc/article/download/1719/1465
                    Dermatology Practical & Conceptual


  Yellow Plugs: An Additional Dermoscopic Criterion
     in the Diagnosis of Primary Cutaneous B-Cell
                      Lymphoma
      Claudio Conforti1, Roberta Giuffrida2, Arianna Dri1, Iris Zalaudek1, Nicola Di Meo1


1 Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
2 Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Italy



Key words: cutaneous lymphoma, dermoscopy, lymphomas, diagnosis
Citation: Conforti C, Giuffrida R, Dri A, Zalaudek I, Di Meo N. Yellow plugs: an additional dermoscopic criterion in the diagnosis of
primary cutaneous b-cell lymphoma. Dermatol Pract Concept. 2022;12(1):e2022006. DOI: https://doi.org/10.5826/dpc.1201a06
Accepted: April 25, 2021; Published: January 2022
Copyright: ©2022 Conforti 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: Roberta Giuffrida, MD, Department of Clinical and Experimental Medicine, Dermatology, University of Messina,
Messina, Italy. Email: roberta_giuffrida@hotmail.it




Introduction                                                            borders, that had been enlarging over the past 8 years.
                                                                        The largest nodule was 30 mm in diameter (Figure 1A).
Primary cutaneous B-cell lymphoma (PCBCL) is a lymphopro-               The patient denied correlation with traumas or arthropods
liferative B-cell disorder involving only the skin at the time of       bites and felt no local pain or itch. No other cutaneous lesions
diagnosis. PCBCLs comprise a group of rare disease that account         were found at total-body checkup. Systemic involvement
for 20%-25% of all cutaneous lymphomas, and they are clas-              was ruled out with laboratory tests, ultrasound examination
sified into 3 main types: (i) follicle center lymphoma (the most        of lymph node stations, and computed axial tomography of
common and usually indolent), (ii) marginal zone lymphoma,              chest and abdomen.
and (iii) diffuse large B-cell lymphoma (the most aggressive) [1].           Dermoscopic evaluation (×20; DermLite, 3Gen) showed
                                                                        the presence of an erythematous background with salm-
                                                                        on-colored areas, arborizing vessels, and peculiar yellow
Case Presentation
                                                                        plugs surrounded by well-defined white circles (Figure 1B).
We present the case of a 63-year-old otherwise healthy Cau-             The integration of the clinical history and information pro-
casian woman who sought consultation at our skin cancer                 vided by dermoscopy led to the hypothesis of B-cell lym-
department for a cluster of lesions localized on the right              phoma. A 5-mm punch biopsy was performed, and the
cheek, presenting as pinkish-erythematous, slow-growing,                histopathological report confirmed the clinical diagnosis of
firm nodules, irregularly oval in shape, with well-defined              cutaneous B-cell lymphoma, follicle center subtype.




Research Letter | Dermatol Pract Concept. 2022;12(1):e2022006                                                                           1
      Figure 1. (A) Clinical image of the follicle center of PCBCL: pinkish-erythematous firm nodules, irregularly oval in shape,
      with well-defined borders, located on the cheek. (B) Dermoscopy of the follicle center of PCBCL: erythematous background,
      salmon-colored areas, arborizing vessels, and yellow plugs surrounded by well-defined white circles.




      Figure 2. (A) Tissue fragment of PCBCL obtained by punch biopsy (standard H&E, magnification ×10). (B) Histopatho-
      logical picture of the lymphoma: nodular lymphoid infiltrates arranged in a follicular pattern in the dermis (standard H&E,
      magnification ×20).



Conclusions                                                          diagnosis, even if dermoscopy can help rule out other skin
                                                                     disorders [2].
Overall, PCBCLs may clinically appear as papules, plaques,               Currently available literature states that white circles and
or nodules of different shapes, number, colors, and body             salmon-colored areas are the main common dermoscopic
locations. Differential diagnosis includes a wide spectrum           features of PCBCLs. Regarding vascularization, arborizing or
of pathologies, such as basal cell carcinoma, amelanotic             serpentine vessels could be found, sometimes simultaneously,
melanoma, arthropod bite scar, or keloid, and for this rea-          resulting in a polymorphous vascular pattern. Scales are a
son a skin biopsy is always needed to arrive at the correct          further criterion highlighted in a retrospective study [3-5].



2                                                                         Research Letter | Dermatol Pract Concept. 2022;12(1):e2022006
The presence of yellow plugs dermoscopic examination of           further investigations are needed to deepen the knowledge
PCBCLs have yet to be reported.                                   on the subject.
   In our patient, yellow plugs were detectable throughout           Informed consent: Written informed consent for pub-
the entire lesion, and particularly evident in the central        lication of her clinical details and clinical images was
area. The term “yellow plugs” refers to yellow structures         obtained from the patient.
surrounded by white circles combined with an erythematous
background with salmon-colored areas and arborizing ves-
                                                                  References
sels. The histopathological examination described nodular
lymphoid infiltrates arranged in a follicular pattern in the      1. Willemze R, Cerroni L, Kempf W, et al. The 2018 update of
dermis. The follicles were atypical because of the absence of        the WHO-EORTC classification for primary cutaneous lym-
                                                                     phomas. Blood. 2019;133(16):1703-1714. DOI: 10.1182/
polarization and mantle and showed a reduction in the num-
                                                                     blood-2018-11-881268. PMID: 30635287. PMCID:
ber of macrophages (Figure 2, A and B). The cell immuno-
                                                                     PMC6473500.
phenotypic patterns were CD20+, Bcl-6+, CD10+ and partial         2. Conforti C, Giuffrida R, Vezzoni R, Resende FSS, di Meo N,
Bcl-2+. There was no evidence of adnexal involvement, so it          Zalaudek I. Dermoscopy and the experienced clinicians. Int J Der-
can be assumed that the accentuated follicular plugging was          matol. 2019 Jun 20. DOI: 10.1111/ijd.14512. PMID: 31222814.
the result of the upward displacement of the epidermis by the     3. Mascolo M, Piccolo V, Argenziano G, et al. Dermoscopy pat-
                                                                     tern, histopathology and immunophenotype of primary cuta-
underlying conspicuous dermal infiltrate.
                                                                     neous b-cell lymphoma presenting as a solitary skin nodule.
   Although dermoscopy cannot replace the histopatho-
                                                                     Dermatology. 2016;232(2):203-207. DOI: 10.1159/000442251.
logical examination, the combination of an erythematous              PMID: 26694025.
background, salmon-colored areas, white circles, arborizing       4. Geller S, Marghoob AA, Scope A, Braun RP, Myskowski PL.
vessels and/or scales, as previously reported by other authors,      Dermoscopy and the diagnosis of primary cutaneous B-cell
as well as peculiar yellow plugs, may be helpful in consider-        lymphoma. J Eur Acad Dermatol Venereol. 2018;32(1):53-56.
                                                                     DOI: 10.1111/jdv.14549. PMID: 28846171; PMCID:
ing PCBCLs in the differential diagnosis of cutaneous pink
                                                                     PMC5773353.
nodules. The peculiar features listed can help in promptly
                                                                  5. Bombonato C, Pampena R, Lallas A, Giovanni P, Longo C.
suspecting a possible lymphoma and in identifying the correct        Dermoscopy of lymphomas and pseudolymphomas. Dermatol
site for biopsy. Moreover, dermoscopy can be used to monitor         Clin. 2018;36(4):377-388. DOI: 10.1016/j.det.2018.05.005.
recurrences. Since PCBCLs comprise a group of rare diseases,         PMID: 30201147.




Research Letter | Dermatol Pract Concept. 2022;12(1):e2022006                                                                       3
