OBSERVATION

ONLINE FIRST
Cutaneous B-Cell Neoplasms Mimicking
Granulomatous Rosacea or Rhinophyma
Aviv Barzilai, MD, MSc; Hana Feuerman, MD; Pietro Quaglino, MD; Michael David, MD;
Meora Feinmesser, MD; Marisa Halpern, MD; Edit Feldberg, MD; Carlo Tomasini, MD;
Hilla Tabibian-Keissar, PhD; Ninette Amarilgio, PhD; Emmilia Hodak, MD

Background: Unlike T-cell neoplasms, B-cell lympho-
proliferative disorders have a limited clinical spectrum
of skin involvement. Cutaneous B-cell neoplasms mim-
icking rosacea or rhinophyma are rare.
Observations: We described 12 patients with B-cell
lymphoproliferative neoplasms presenting with a facial
eruption clinically mimicking rosacea or rhinophyma.
Eleven patients were women; ages ranged from 36 to 81
years. The clinical presentation included small papules
on the nose and cheeks and around the eyes mimicking
granulomatous rosacea; nodules on the nose, cheeks,
chin, or forehead mimicking phymatous rosacea; or a
combination of both. Three patients had preexisting
erythematotelangiectatic rosacea and 1 had rhino-
phyma. Based on a clinicopathologic correlation and
B-cell clonality analysis, the diagnosis was primary
cutaneous follicular center B-cell lymphoma in 4 cases,
primary cutaneous marginal zone lymphoma in 6, and
skin involvement of chronic lymphocytic leukemia in 2.
All patients had an indolent course as expected for their
disease.
Conclusions: Cutaneous involvement of B-cell neo-
plasms may mimic granulomatous rosacea or rhino-
phyma. This unusual clinical presentation is more com-
mon in women and appears in the setting of preexisting
rosacea or as a new eruption. Proliferative B-cell disor-
ders should be added to the differential diagnosis of sym-
metric papular or papulonodular eruptions of the face.
Arch Dermatol. 2012;148(7):824-831.
Published online April 16, 2012.
doi:10.1001/archdermatol.2011.3575

Author Affiliations are listed at
the end of this article.
B
-CELL NEOPLASMS CAN IN-
volve the skin as a primary
cutaneous lymphoma or as
a secondary process, includ-
ing specific infiltrates of
nodal or extranodal lymphoma or leuke-
mia.1 When involving the skin, both B-
cell neoplasms, lymphoma and leuke-
mia, have a distinct clinical appearance,
presenting as isolated, grouped, or mul-
tiple erythematous to violaceous pap-
ules, plaques, or nodules, usually in an
asymmetric distribution. B-cell lympho-
proliferative diseases simulating rosacea are
extremely rare.2-8 In this report, we de-
scribe 12 patients who presented with ro-
sacea or rhinophymalike lesions and dis-
cuss various aspects of this rare clinical
manifestation of low-grade B-cell lym-
phoma/leukemia involving the face.
METHODS
We performed a retrospective case analysis of
12 patients with cutaneous B-cell neoplasms
who were referred to our tertiary dermatology
clinics from January 1, 1996, through Decem-
ber 31, 2010, for a persistent facial rash. The
differential diagnoses included rosacea and
rhinophyma. We retrieved clinical history,
clinical findings, laboratory results, and
follow-up data from the medical files and
reviewed the biopsy specimens. Final diagno-
sis was made according to the criteria of the
World Health Organization or the European
Organization for Research and Treatment of
Cancer.1 The study was approved by the local
ethics committees.
RESULTS
The patients’ clinical data and final diag-
noses are described in Table 1 . The
study group included 11 women and 1
man with a mean age of 57 (range,
36-81) years. The time elapsed from the
initial presentation to the final diagnosis
varied from a few months to 10 years
(mean time, 23 months). The distin-
guishing features of the clinical presenta-
tion included nonpustular granuloma-

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 Table 1. Clinical Data and Final Diagnosis in Patients With B-Cell Neoplasms Mimicking Rosacea or Rhinophyma

Patient No./ Duration Before Final

Sex/Age, y Diagnosis Clinical Presentation Initial Diagnosis Early Therapy Diagnosis
1/F/51 3y Papulonodular eruption on the Rosacea and rhinophyma Minocycline hydrochloride, PCFCL
cheeks; erythematous infiltrated topical metronidazole
plaque on the nose
2/F/48 4 mo Erythematous infiltrated plaque on the Rhinophyma None PCFCL
nose on top of rosacea
3/F/36 3y Facial erythematous and skin-colored Rosacea Erythromycin, minocycline PCMZL
papules with erythema and
telangiectasia
4/F/67 6 mo Nodular eruption on nose, cheeks, Rosacea and rhinophyma Topical clindamycin CLL, leukemia
and chin phosphate cutis
5/F/81 3y Erythematous infiltrated plaque on the Rhinophyma None PCMZL
nose
6/F/60 4 mo Erythema on the distal part of the Sebaceous hyperplasia, None PCMZL
nose with 3 small nodules basaliomas;
granulomatous rosacea
7/F/52 6 mo Small erythematous papules on Granulomatous rosacea None PCMZL
cheeks but also on neck, nape, and
chest
8/F/57 6 mo Small skin-colored to erythematous Granulomatous rosacea, None PCFCL
papules on cheek, sides of the basaliomas, sebaceous
nose, eyebrows, helices, and upper hyperplasia
back
9/F/36 6 mo Erythematous papules around the Granulomatous rosacea, Liquid nitrogen PCMZL
mouth, including the chin and on sarcoidosis, and
the nose molluscum
10/M/74 10 y Erythematous infiltrated nodular Rhinophyma Azithromycin, topical CLL, leukemia
lesion on the nose metronidazole cutis
11/F/70 1y Erythematous plaques on the nose Granulomatous rosacea, Topical metronidazole PCMZL
and cheeks sarcoidosis
12/F/49 6 mo Erythematous infiltrated plaque on the Granulomatous rosacea Topical metronidazole PCFCL
left ala nasi

Abbreviations: CLL, chronic lymphocytic leukemia; PCFCL, primary cutaneous follicular center cell lymphoma; PCMZL, primary cutaneous marginal zone
lymphoma.

Figure 1. Erythematous (granulomatous rosacea-like) papules on the right

cheek in a patient with primary cutaneous follicular center B-cell lymphoma Figure 2. Rhinophymalike lesion in a patient with primary cutaneous
(patient 1). marginal zone lymphoma (patient 11).

tous rosacea-like lesions and rhinophyma/phymatous

plaques (Table 1, Figure 1 , and Figure 2 ). Four
patients (patients 1-3 and 10) had a history of preexist-
ing rosacea manifesting as erythematotelangiectatic
rosacea (in 3 patients) and rhinophyma (in 1 patient)
(Figure 3). Two of these patients developed rhinophy-
malike lymphoma on the nose. Half the patients were
treated for rosacea with topical or systemic antibiotics
or both, without any benefit (Table 1).
The histological and immunophenotypical features
of the cases and the results of molecular studies are
described in Table 2. Four cases revealed superficial
and deep nodular aggregates of centrocytes and centro-
blasts, features of follicular-center cell lymphoma
(Figure 4). Six cases showed superficial and deep
nodular aggregates of small irregular B lymphocytes,
some with a monocytoid or plasmacytoid appearance

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Figure 3. Papular/granulomatous rosacea-like lesions on the background of
preexisting erythematotelangiectatic rosacea. Small erythematous papules
that were determined to be primary cutaneous marginal zone lymphoma
were found on erythema and telangiectasia (patient 3). This patient had
papules on both cheeks and also on the submental areas.
and residual fragmented germinal centers, features of mar-
ginal cell lymphoma (Figure 5). Two cases had diffuse
dermal infiltrates of mostly small regular B cells
(Figure 6), consistent with skin involvement by chronic
lymphocytic leukemia (CLL). Furthermore, in patient 4,
results of an IgH rearrangement study showed an iden-
tical clone in the blood and skin (Figure 6), establishing
the diagnosis of leukemia cutis. Demodex folliculorum was
not present in any of the biopsy specimens.
Based on a full workup including clinicopathologic cor-
relation and analysis of B-cell clonality, the diagnosis re-
tained was primary cutaneous follicular center B-cell lym-
phoma in 4 of 12 cases (33%), primary cutaneous marginal
zone lymphoma in 6 (50%), and skin involvement of CLL
in 2 (17%) (Table 2). All the patients had an indolent
course as expected for their disease. Initial therapy, which
included radiotherapy and/or excisions for 8 patients with
primary cutaneous B-cell lymphoma (PCBCL), led to com-
plete remission. However, in patients 3 and 8, new le-
sions developed at sites not previously treated. Intral-
esional or potent topical corticosteroids applied to these

Table 2. Histological, Immunophenotypical, and Molecular Characteristics of Cases of B-Cell Neoplasms Mimicking Rosacea
and Rhinophyma

Histological Features
Patient IgH Gene Final
No. Architecture Cells Immunophenotype Rearrangement Diagnosis
1 Superficial and deep nodular Small and large (centrocytes, Positive for CD20 and CD10 in germinal center–like ND PCFCL
centroblasts) structures; negative for bcl-2
2 Superficial and deep, nodular Small and large, regular and Positive for CD20, bcl-6, and CD10 in follicular Monoclonal PCFCL
and diffuse irregular center cells; CD23 in nonfollicular center cells; and
CD3 small cells between aggregates
3 Superficial and deep, nodular Small irregular and monocytoid Positive for CD20 and bcl-2 in T cells and marginal Monoclonal PCMZL
and diffuse, follicular in marginal areas and areas, bcl-6 and CD10 in germinal centers, and
colonization, prominent between germinal centers CD3 in small cells
marginal zone
4 Diffuse infiltrate involving the Small regular and slightly Positive for CD20 and CD23; negative for CD5 Same clone in Cutaneous
whole dermis, with areas of irregular, prolymphocytes the skin and localization
proliferation centers and paraimmunoblasts in peripheral of B-CLL
proliferation centers blood
5 Superficial and deep nodular, Irregular small lymphocytes, Positive for CD20 and bcl-2 in the small irregular Monoclonal PCMZL
small remnants of germinal also at the periphery of the lymphocytes, bcl-6 in remnants of germinal
centers nodules, few plasma cells centers, and CD3 in T cells at the periphery of the
nodules; some plasma cells, lambda predominates
6 Superficial and deep nodular Small irregular, some Positive for CD20(⫹⫹) and CD3(⫹) at the Monoclonal PCMZL
aggregates, few small monocytoid periphery, bcl-2 in small B and T cells, and CD10
germinal centers in germinal centers
7 Superficial and deep nodular, Small irregular cells, plasma Positive for CD20 and bcl-2 in most of the cells, Polyclonal PCMZL
residual germinal centers cells bcl-6 and CD10 in residual germinal centers, and
CD3 in small T cells
8 Superficial and deep nodular Small and large, regular and Positive for CD20, CD45RA, bcl-6, and CD10 in Monoclonal PCFCL
aggregates, focally irregular follicle center cells; bcl-2 in some of the B cells
fragmented germinal centers and in T cells; and CD3
9 Diffuse infiltrate involving the Small irregular lymphocytes, Positive for CD20 (approximately 50%) and bcl-2 in Polyclonal PCMZL
whole dermis plasmacytoid and plasma B and T cells; negative for bcl-6; many plasma
cells cells, lambda predominates
10 Diffuse infiltrate involving the Small and medium lymphoid Positive for CD5, CD20, and bcl-2; negative for bcl-6; Monoclonal Cutaneous
deep dermis and cells, reactive T lymphocytes, clonal expression of ␬ light chain localization
subcutaneous tissue few histiocytes of B-CLL
11 Nodular infiltrate involving the Small lymphocytes, reactive Negative for CD10; positive for CD20 and bcl-2; a Monoclonal PCMZL
whole dermis with a grenz T cells, some histiocytes few bcl-6–positive follicle center cells; no light
zone toward the epidermis chain restrictions
12 Nodular infiltrate involving the Small and medium lymphoid Positive for CD20 and bcl-6; negative for CD10; Polyclonal PCFCL
whole dermis with a grenz cells, reactive T cells, few no light chain restriction
zone toward the epidermis, histiocytes and plasmocytes
focally germinal centers

Abbreviations: B-CLL, B-cell chronic lymphocytic leukemia; ND, testing not performed; PCFCL, primary cutaneous follicular center cell lymphoma; PCMZL, primary
cutaneous marginal zone lymphoma.

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A
B described previously6 had preexisting rosacea present-
C nosis delay that ranged from months to years. Half the
Figure 4. Histological features of primary cutaneous follicular center B-cell
lymphoma (patient 8). A, Superficial and deep nodular aggregates show
irregular lymphoid germinal center–like areas (hematoxylin-eosin, original
magnification ⫻20). B and C, The areas are composed of small and large B
lymphocytes (hematoxylin-eosin [B] and CD20 [C], original magnification
⫻400).
small lesions led to complete remission. The cutaneous
lesions of CLL resolved completely after a course of pred-
nisone and chlorambucil therapy in patient 4 and ritux-
imab and radiotherapy in patient 10. Two patients had
only received the diagnosis at the time of this report, and
follow-up was not available.
COMMENT
B-cell lymphoproliferative diseases clinically mimicking
rosacea are extremely rare and have been previously
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reported in only 7 cases detailed in Table 3. The find-
ings of the present case series of 12 patients with B-cell
lymphoproliferative diseases simulating granulomatous
rosacea, rhinophyma, or both are comparable to those
reports. Likewise, most of our patients were women.
However, our patients were somewhat younger than
those described in the previous reports (mean age, 57
vs 76 years), making the initial diagnosis of rosacea
more plausible. Clinically, all our patients presented
with phymatous lesions (mostly rhinophyma), granulo-
matous rosacea-like lesions, or both. In contrast, all
previously described patients who had PCBCL had phy-
matous lesions.3-7 Three patients described herein and 1
ing as facial flushing, erythema, and telangiectasia.
Therefore, the development of papules or rhinophyma
in these patients was considered part of the preexisting
rosacea. Two patients described in the literature also
had pustules,2,8 and both of them had CLL. In one of
those patients, earlier biopsy findings showed polymor-
phonuclear leukocytes, which probably represented
preexisting rosacea.2 In the other patient, histological
features of the pustules were not described. Thus, pus-
tules might have formed secondary to occlusion of the
folliculosebaceous unit by the leukemic infiltrate.8 In
contrast, none of the patients described herein had a
pustular eruption.
This unique clinical presentation of B-cell neoplasm
involving the skin and simulating rosacea led to a diag-
patients in the present series (6 of 12) and most of the
patients described in the literature (6 of 7)2-7 had been
initially treated with topical or systemic antibiotics for
at least a few months without any benefit before a
biopsy specimen was obtained. Thus, rosacea and rhi-
nophyma should be added to the list of the unusual
manifestations of B-cell neoplasms simulating other
skin diseases (Table 4). The clinical differential diag-
nosis of these lesions does not include only rosacea. For
the papular/granulomatous rosacea-like lesions, the dif-
ferential diagnosis would include mostly adnexal
tumors, such as basal cell carcinoma, trichoepithelioma,
or sebaceous hyperplasia, and cutaneous sarcoidosis.
For the phymatous lesions, granulomatous diseases (in-
fectious or noninfectious) and T-cell lymphoma should
be considered.
Fifteen of the 19 total patients (10 in the present se-
ries and 5 in previously reported cases) had PCBCL,
with the marginal zone lymphoma being the most com-
mon (10 of 19 patients, including 1 with immunocy-
toma, currently considered a type of marginal zone
lymphoma) followed by follicular center cell lymphoma
(5 of 19 patients). In 4 patients, the skin infiltrative le-
sions represented leukemia cutis of CLL. In general, pri-
mary cutaneous marginal zone lymphoma is uncom-
monly located on the face.1 One may therefore speculate
that chronic antigenic stimulation caused by a resident
organism such as D folliculorum leads to the development
of the lymphoma similar to the relation between Helico-
bacter pylori and gastric lymphoma.19 Although we did
not observe Demodex organisms in any of the biopsy speci-
mens, such a mechanism is plausible because it would
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 A B

C D

Figure 5. Histological features of primary cutaneous marginal zone lymphoma (patient 3). A, Superficial and deep nodular aggregates are seen
(hematoxylin-eosin, original magnification ⫻20). B and C, The aggregates show distended marginal zones of monocytoid B cells (hematoxylin-eosin [B] and CD20
[C], original magnification ⫻200). C, The residual germinal center reveals positive staining for CD20 and negative staining for bcl-2. D, The marginal B cells are
positive for bcl-2 (original magnification ⫻200).

account for the lymphoma development and the clinical
presentation.20 Alternatively, similar to descriptions of
leukemic infiltrates of CLL localized to the sites of her-
pes zoster,14,15 the lymphomatous/leukemic infiltrates
localized to the face may represent the isomorphic
phenomenon on the sites of a preexisting rosacea/
rhinophyma.
In all 19 reported cases, the diagnosis was based on
histological and immunophenotypical characteristics,
supported in most of the cases by genotypic findings.
Demonstration of a monotypic plasma cell population
or IgH gene rearrangement is crucial for the diagnosis
of primary cutaneous marginal zone lymphoma in this
setting because some cases of rosacea may show dense
lymphohistoplasmacytic infiltrate.21 It is also essential
to show the identical clone of B cells in the skin infil-
trate and in the blood in cases of CLL, especially if
the findings for CD5 are negative (as in patient 4)
or when a concomitant B-cell lymphoma has to be
excluded.
The PCBCLs were treated with excision or radio-
therapy, as indicated for low-grade PCBCL.22 In con-
trast, skin infiltrates of CLL in which most of the cells
are small are related to a favorable prognosis and do not
require specific therapy.23 However, in cases in which they
pose an aesthetic problem, such as those described in the
present series, radiotherapy and even systemic therapy
may be indicated. For small papules and nodules that con-
tinue to appear, topical corticosteroids may be the treat-
ment of choice for early lesions. This modality may be
more practical and accepted from the cosmetic point of
view, probably without affecting the course of the dis-
ease. Nevertheless, further studies are needed to vali-
date this approach, particularly in cases of follicular cen-
ter B-cell lymphoma.
In summary, cutaneous involvement by B-cell neo-
plasms may mimic rosacea or rhinophyma. This un-
usual clinical presentation is more common in women
and appears in the setting of preexisting rosacea or as a
new eruption. A B-cell proliferative disorder presenting

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 A B

C D

Figure 6. Leukemia cutis of chronic lymphocytic leukemia mimicking phymatous rosacea (patient 4). A, Erythematous plaques and nodules on the nose, cheeks,
and chin. B, Diffuse lymphocytic infiltrate involving the dermis (hematoxylin-eosin, original magnification ⫻40). C, The infiltrate is composed of small round
lymphocytes and larger cells (prolymphocytes and paraimmunoblasts) (hematoxylin-eosin, original magnification ⫻400). D, Results of the IgH study show
identical clones (dark filled peaks marked by arrows at 125 kilobase) in the skin biopsy specimen (top) and in the peripheral blood (bottom). The y-axes show
peak intensity, measured in arbitrary units; the x-axes show DNA fragment size, measured in kilobases.

Table 3. Reports of B-Cell Neoplasms Mimicking Rosacea or Rhinophyma: Review of the Literature

Patient No./
Sex/Age, y Clinical Presentation/Initial Diagnosis Early Therapy Final Diagnosis Source
1/F/69 Erythematous papules and pustules on the cheeks, Tetracycline hydrochloride CLL Thomson and Cochran,2
forehead, and chin/rosacea 1978
2/F/50 Multiple erythematous infiltrated nodules and plaques Topical metronidazole, PCMZL Colvin et al,3 2003
over face and ears/granulomatous rosacea minocycline (immunocytoma)
hydrochloride
3/F/86 Indurated, well-demarcated, erythematous to Topical metronidazole PCFCL Seward et al,4 2004
violaceous nodule extending from the midnasal
bridge to the nasal tip/rhinophyma
4/F/83 Erythema and swelling of the nose/rhinophyma (also Minocycline PCMZL Stanway et al,5 2004
nodule on pinna of the ear and nail fold swelling)
5/F/78 Nontender erythematous nodules and plaques at tip of Erythromycin, acyclovir PCMZL Ogden and Coulson,6
nose/rhinophyma sodium 2008
6/F/80 Slightly infiltrated painless erythematous plaque Minocycline PCMZL Rosmaninho et al,7
localized on tip of nose/rhinophyma 2010
7/F/83 Infiltrated nodules and plaques on nose, cheeks, and None CLL Bennett et al,8 2010
periorbitally; papules and pustules; sebaceous
hyperplasia; and telangiectasia/rosacea and
rhinophyma

Abbreviations: CLL, chronic lymphocytic leukemia; PCFCL, primary cutaneous follicular center cell lymphoma; PCMZL, primary cutaneous marginal zone
lymphoma.

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 Correspondence: Aviv Barzilai, MD, MSc, Department
Table 4. Unusual Clinical Manifestations of Cutaneous of Dermatology, Sheba Medical Center, 52621 Tel-
B-Cell Neoplasms Hashomer, Israel (avivb@post.tau.ac.il).
Author Contributions: Drs Barzilai, Feuerman, Qua-
B-Cell Neoplasm Clinical Appearance Selected Source
glino, and Hodak had full access to all the data in the
CLL Papules in a Wakelin et al,14 study and take responsibility for the integrity of the
dermatomal 1997
data and the accuracy of the data analysis. Study concept
distribution (after Claeys et al,15
herpes zoster) 2008 and design: Barzilai, Feuerman, and Hodak. Acquisition
CLL Fingertip Freiman et al,16 of data: Barzilai, Feuerman, Quaglino, and Hodak.
hypertrophy 2003 Analysis and interpretation of data: Barzilai, Feuerman,
MZL/FCC/CLL Rosacea/rhinophyma Present series Quaglino, David, Feinmesser, Halpern, Feldberg, To-
Thomson and
masini, Tabibian-Keissar, Amarilgio, and Hodak. Draft-
Cochran,2
1978 ing of the manuscript: Barzilai. Critical revision of the
Colvin et al,3 manuscript for important intellectual content: Barzilai,
2003 Feuerman, Quaglino, David, and Hodak. Administrative,
Seward et al,4 technical, and material support: Feinmesser, Tabibian-
2004
Stanway et al,5
Keissar, and Amarilgio. Study supervision: Barzilai and
2004 Hodak.
Ogden and Financial Disclosure: None reported.
Coulson,6
2008
Rosmaninho et REFERENCES
al,7 2010
Bennett et al,8
2010 1. Willemze R, Jaffe ES, Burg G, et al. WHO-EORTC classification for cutaneous
FCC/MZL Anetoderma Hodak et al,9 lymphomas. Blood. 2005;105(10):3768-3785.
2010 2. Thomson J, Cochran RE. Chronic lymphatic leukemia presenting as atypical ro-
MZL Lipoma Paulli et al,11 sacea with follicular mucinosis. J Cutan Pathol. 1978;5(2):81-87.
(subcutaneous) 2010 3. Colvin JH, Lamerson CL, Cualing H, Mutasim DF. Cutaneous lymphoplasmacy-
Large B-cell lymphoma Cutaneous horns Dasgupta et al,10 toid lymphoma (immunocytoma) with Waldenström’s macroglobulinemia mim-
2006 icking rosacea. J Am Acad Dermatol. 2003;49(6):1159-1162.
Large B-cell lymphoma, Chronic venous Garbea et al,12 4. Seward JL, Malone JC, Callen JP. Rhinophymalike swelling in an 86-year-old wom-
leg type ulcer 2002 an: primary cutaneous B-cell lymphoma of the nose. Arch Dermatol. 2004;
Intravascular Livedo reticularis Röglin and 140(6):751-756.
lymphoma and livedo Böer,13 2007 5. Stanway A, Rademaker M, Kennedy I, Newman P. Cutaneous B-cell lymphoma
vasculitis of nails, pinna and nose treated with chlorambucil. Australas J Dermatol. 2004;
Secondary involvement Mycosis fungoides Chui et al,17 1999 45(2):110-113.
of the skin by MZL Chiang et al,18 6. Ogden S, Coulson IH. B-cell lymphoma mimicking rhinophyma. Clin Exp Dermatol.
2010 2008;33(2):213-214.
7. Rosmaninho A, Alves R, Lima M, Lobo I, Amorim I, Selores M. Red nose: pri-
Abbreviations: CLL, chronic lymphocytic leukemia; FCC, follicular center cell; mary cutaneous marginal zone B-cell lymphoma. Leuk Res. 2010;34(5):682-
MZL, marginal zone lymphoma. 684.
8. Bennett M, Higgins E, Curran S, Marren P. Leukaemia cutis mimicking florid rhi-
nophymatous rosacea [abstract 13]. Br J Dermatol. 2010;163:443. doi:10.1111
in the skin should be added to the long list of diseases /j.1365-2133.2010.09921.x.
9. Hodak E, Feuerman H, Barzilai A, David M, Cerroni L, Feinmesser M. Anetoder-
affecting the face manifested by rhinophyma or papulo- mic primary cutaneous B-cell lymphoma: a unique clinicopathological presen-
nodular rosacea-like eruptions. tation of lymphoma possibly associated with antiphospholipid antibodies. Arch
Dermatol. 2010;146(2):175-182.
10. Dasgupta S, Mitra D, Bhattacharya A, Sur PK. B cell lymphoma with unusual clini-
Accepted for Publication: December 29, 2012.
cal cutaneous presentation. J Cancer Res Ther. 2006;2(4):203-205.
Published Online: April 16, 2012. doi:10.1001 11. Paulli M, Arcaini L, Lucioni M, et al. Subcutaneous “lipoma-like” B-cell lym-
/archdermatol.2011.3575 phoma associated with HCV infection: a new presentation of primary extra-
Author Affiliations: Departments of Dermatology (Dr Bar- nodal marginal zone B-cell lymphoma of MALT. Ann Oncol. 2010;21(6):1189-
zilai) and Pathology (Drs Barzilai and Tabibian-Keissar) 1195.
12. Garbea A, Dippel E, Hildenbrand R, Bleyl U, Schadendorf D, Goerdt S. Cutane-
and Hematology Institute (Dr Amarilgio), Sheba Medi- ous large B-cell lymphoma of the leg masquerading as a chronic venous ulcer.
cal Center, Tel-Hashomer, Israel; Departments of Der- Br J Dermatol. 2002;146(1):144-147.
matology (Drs Feuerman, David, and Hodak) and Pa- 13. Röglin J, Böer A. Skin manifestations of intravascular lymphoma mimic inflam-
thology (Drs Feinmesser and Halpern), Beilinson Hospital, matory diseases of the skin. Br J Dermatol. 2007;157(1):16-25.
Rabin Medical Center, Petach-Tikva, Israel; Sackler Fac- 14. Wakelin SH, Young E, Kelly S, Turner M. Transient leukaemia cutis in chronic
lymphocytic leukaemia. Clin Exp Dermatol. 1997;22(1):37-40.
ulty of Medicine, Tel-Aviv University, Tel-Aviv, Israel 15. Claeys A, Pouaha J, Christian B, Froment N, Truchetet F. Zosteriform cutaneous
(Drs Barzilai, Feuerman, David, Feinmesser, Halpern, and localizations of B-cell chronic lymphocytic leukaemia. Eur J Dermatol. 2008;
Hodak); Department of Pathology, Kaplan Medical Cen- 18(1):101-102.
ter, Rehovot, Israel (Drs Barzilai and Feldberg); and De- 16. Freiman A, Muhn CY, Trudel M, Billick RC. Leukemia cutis presenting with fin-
partment of Biomedical Sciences and Human Oncology, gertip hypertrophy. J Cutan Med Surg. 2003;7(1):57-60.
17. Chui CT, Hoppe RT, Kohler S, Kim YH. Epidermotropic cutaneous B-cell lym-
Dermatologic Clinic (Dr Quaglino) and Laboratory of Cu- phoma mimicking mycosis fungoides. J Am Acad Dermatol. 1999;41(2, pt 1):
taneous Pathology (Dr Tomasini), University of Turin, 271-274.
Turin, Italy. 18. Chiang S, DiCaudo DJ, Valdez R, Swanson DL. Cutaneous B-cell lymphoma with

ARCH DERMATOL/ VOL 148 (NO. 7), JULY 2012 WWW.ARCHDERMATOL.COM

830

©2012 American Medical Association. All rights reserved.

Downloaded From: http://archderm.jamanetwork.com/ by a GLASGOW UNIVERSITY LIBRARY User on 10/10/2015
 histologic features of mycosis fungoides. J Am Acad Dermatol. 2010;62(2):
320-323.
19. Sagaert X, Van Cutsem E, De Hertogh G, Geboes K, Tousseyn T. Gastric MALT
lymphoma: a model of chronic inflammation-induced tumor development. Nat
Rev Gastroenterol Hepatol. 2010;7(6):336-346.
20. Yamasaki K, Gallo RL. The molecular pathology of rosacea. J Dermatol Sci. 2009;
55(2):77-81.
21. Aroni K, Tsagroni E, Lazaris AC, Patsouris E, Agapitos E. Rosacea: a clinico-
pathological approach. Dermatology. 2004;209(3):177-182.
22. Senff NJ, Noordijk EM, Kim YH, et al; European Organization for Research and
Treatment of Cancer; International Society for Cutaneous Lymphoma.
European Organization for Research and Treatment of Cancer and Interna-
tional Society for Cutaneous Lymphoma consensus recommendations for
the management of cutaneous B-cell lymphomas. Blood. 2008;112(5):1600-
1609.
23. Kaddu S, Smolle J, Cerroni L, Kerl H. Prognostic evaluation of specific cutane-
ous infiltrates in B-chronic lymphocytic leukemia. J Cutan Pathol. 1996;23
(6):487-494.

Notable Notes

Morbus Europaeus: Europeans Naming Syphilis for Their Enemies

The Spanish physician Rodrigo Ruiz Diaz de Isla attributed the
entryofsyphilisinEuropetoChristopherColumbus,whobrought
itfromtheNewWorld(1493).1 AfterKingCharlesVIIIconquered
the Neapolitan kingdom, the French called syphilis maladie de
Naples or mal napolitain. Interestingly, Italians Luca Ghini and
Nicola Massa used the name morbus neapolitanus in the titles of
their 2 works, respectively.2 After the battle of Fornovo, with a
victory by the Italian League over the French army commanded
by Charles VIII, syphilis was called male italiano or morbo italico.3
Syphilis became the symbol of shame that was used by people
to cast aspersion on their enemies. It was named morbo lusitano
by the Castilians and mal castigliano by the Lusitans, showing the
ancient acrimony between them. Castilians also called syphilis
mal di Galizia, referring to both Catholic kings Isabella of Cas-
tile and Ferdinand of Aragon. Turks used the name mal dei cris-
tiani, underscoring the never-ending hostility between Turks and
Christians.Intheearly16thcentury,theDutchandFlemishcalled
syphilis morbo spagnolo, in commemoration of the Spanish in-
vasion. Russians used the synonyms mal dei Polacchi and mal
polacco as they expanded into Poland, but the Polish, who did
not insult the Russians, used the synonym mal dei Tedeschi.4
Morbus europaeus was justified because syphilis spread
through all of Europe and beyond. Pietro Rostino used the
term male indiano, referring to the New World; Antonio Sca-
naroli more precisely used mal d’America; and Francois Xavier
Swediaur used mal de la baia di St Paul.5 Syphilis was named
malattia del Portogallo in India because of the undesirable pres-
ence of the Portuguese Vasco de Gama in 1498 and Pedro Al-
varez in 1500 and their men. Firanga was the name used in
Calcutta, in remembrance of the Carlovingian empire. The
Japanese called syphilis mal portoghese as an affront to the Por-
tuguese and ulcera della Cina or veleno di susino to offend the
Chinese. Finally, the Chinese named syphilis ulcera di susino
or eruzione di Canton, after the first Chinese city where syphi-
lis spread.6 Chinese poets compared syphilis to the budding
of a flower without fear of winter, meaning that the appear-
ance of syphilis is both abrupt and startling.
Antonio Tagarelli, MD
Giuseppe Tagarelli, PhD
Paolo Lagonia, PhD
Anna Piro, MD

Author Affiliations: National Research Council of Italy, Institute of Neurological Sciences, Mangone, Cosenza, Italy.
Contact Dr A. Tagarelli at the National Research Council of Italy, Institute of Neurological Sciences, Contrade Burga, Man-
gone, Cosenza 87050, Italy (a.tagarelli@isn.cnr.it).
1. Diaz de Isla R, ed. Tractado llamado fructo de todos los santos contra el mal serpentine venido de la isla Espanola hecho y ordenado en el grande y famoso
hospital de todos los santos. Seville, Spain: A Burgos; 1539.
2. Astruc J, ed. De morbis venereis libri sex. In quibus disseritur tum de origine, propagatione & contagione horumce affectuum in genere: tùm de singulorum
naturà, aetiologiâ & therapeiâ, cum brevi analisi & epicrisi operum plerorumque quae de eodem argomento scripta sunt. Paris, France: G Cavelier; 1736.
3. Rondelet G, ed. Methodus curandorum omnium morbum corpis humani. De morbo gallico. Paris, France: C Maceo; 1754.
4. Pernotti di Cigliano P, ed. Storia generale e ragionata dell’origine, dell’essenza e specifica dell’infezione venerea. Turin, Italy: Stampa Reale; 1788.
5. Swediaur F, ed. Traité complet sur les symptomes, les effets, la nature et le traitment des maladies syphilitiques. Paris, France: Cellot; 1817.
6. Wang N, ed. Dermatologia in medicina tradizionale cinese. Milan, Italy: Ambrosiana; 1997.

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