Peer Reviewed

What's Your Diagnosis?

Localized Papules in a Man with Weakness and Lightheadedness

Dayna Gager, BA,
Shantelle Griffith, MD,
Thomas N. Helm, MD
Volume 66 - Issue 3 - March 2026

  • Answer D. Leukemia cutis

    Differential Diagnosis. There were several differential diagnoses considered. Folliculitis can have a similar clinical presentation but is characterized by papules and pustules associated with a central hair follicle. However, pustules were not encountered in our patient.1 Medication eruptions can present with a broad spectrum of morphologies and primary lesions, and this was considered. However, a biopsy was performed, which ruled out this possibility. Although biopsy following a medication eruption may reveal necrotic keratinocytes, eosinophilic infiltrate, as well as lymphocytes and histiocytes, the infiltrate of atypical myeloid cells noted in our patient would not be expected in a conventional medication reaction.2,3  Urticaria is characterized by transient wheals that resolve within 24 hours; biopsy performed during this window shows a perivascular infiltrate of lymphocytes, neutrophils, and occasional eosinophils.4 

    Treatment and management. The mainstay of treatment for leukemia cutis secondary to acute myeloid leukemia (AML) is chemotherapy. Due to our patient’s extensive cardiac history and intolerance to medications causing orthostatic hypotension, induction chemotherapy was started with azacitidine (5 days) and venetoclax (21 days). 

    Outcome and follow-up. Two weeks after completing his first chemotherapy cycle, bone marrow biopsy revealed 35% residual blasts.  He was readmitted for reinduction with cladribine, cytarabine, filgrastim, and mitoxantrone (CLAG-M) (5 days) and venetoclax 70mg (14 days). Full body computed tomography (CT) scans identified widespread lymphadenopathy, and a right inguinal node biopsy confirmed myeloid sarcoma. His hospital course was complicated by neutropenic fever, gastrointestinal bleed, heart failure exacerbation with fluid overload, and episodes of ventricular tachycardia and fibrillation, prompting transfer to the intensive care unit.  Sadly, the patient died 2 months later.

    Discussion. While any subtype of leukemia can affect the skin, chronic lymphocytic leukemia (CLL) and AML with monocytic or myelomonocytic morphology are the most commonly observed in clinical practice. Skin findings in leukemia cutis can rarely occur in isolation.5,6 In 2-3% of adult patients, skin lesions are the first sign of underlying hematologic malignancy, termed "aleukemia cutis".7 Aleukemia cutis occurs in up to 50% of infants with leukemia and typically appears as diffuse bluish nodules, known as a "blueberry muffin rash".8

    Leukemia cutis often presents as erythematous papules and nodules, but lesions mimicking medication eruptions, folliculitis, vesicles, desquamation, and petechiae have been reported.9  Unique presentations can occur across different skin tones, including pruritus and eyelid edema in skin of color.10 Eruptions preferentially occur at sites of prior inflammation, which may explain why our patient first noticed lesions overlying his pacemaker.

    Individuals affected by AML may present with vague systemic symptoms often associated with benign conditions, making early recognition challenging. Diagnosis of leukemia cutis relies on a combination of clinical features, histopathology, and immunophenotyping, while treatment and prognosis depend on leukemic subtype, gene mutations, risk factors, and comorbidities. Early detection of skin lesions can facilitate earlier diagnosis and initiation of chemotherapy, ultimately improving prognosis.

    AUTHORS:
    Dayna Gager, BA1 • Shantelle Griffith, MD2 • Thomas N. Helm, MD2

    AFFILIATIONS
    1Pennsylvania State College of Medicine, Hershey, Pennsylvania
    2Department of Dermatology, Pennsylvania State Hershey Medical Center, Hershey, Pennsylvania

    CITATION
    Gager D, Griffith S, Helm TN. Localized papules in a man with weakness and lightheadedness. Consultant. Published January 2, 2026. DOI: 10.25270/con.2026.01.000002

    Received February 19, 2025.  Accepted October 29, 2025.

    DISCLOSURES
    None.

    ACKNOWLEDGMENTS
    None.

    CORRESPONDENCE
    Dayna Gager, BA, 700 HMC Crescent Road, Hershey, PA 17033 (email: dgager@pennstatehealth.psu.edu)

    References.

    1. Bolognia JL, Schaffer JV, Duncan KO, Ko CJ. Folliculitis. In: Bolognia JL, Schaffer JV, Duncan KO, Ko CJ, eds. Dermatology Essentials. 2nd ed. Elsevier; 2022:282-297.
    2. Blume JE, Ali L, Ehrlich M, Camisa C, Helm TN. Drug eruptions. Medscape. Updated July 2, 2024. Accessed December 22, 2025. https://emedicine.medscape.com/article/1049474-overview
    3. Bolognia JL, Schaffer JV, Duncan KO, Ko CJ. Drug reactions. In: Bolognia JL, Schaffer JV, Duncan KO, Ko CJ, eds. Dermatology Essentials. 2nd ed. Elsevier; 2022:159-183.
    4. Bolognia JL, Schaffer JV, Duncan KO, Ko CJ. Urticaria and angioedema. In: Bolognia JL, Schaffer JV, Duncan KO, Ko CJ, eds. Dermatology Essentials. 2nd ed. Elsevier; 2022:135-141.
    5. Robak E, Braun M, Robak T. Leukemia cutis: current view on pathogenesis, diagnosis, and treatment. Cancers (Basel). 2023;15(22):5393. doi:10.3390/cancers15225393
    6. Devins K, Kalb RE, Helm TN. Leukemia cutis. Medscape. Updated July 2, 2024. Accessed December 22, 2025. https://emedicine.medscape.com/article/1097702-overview
    7. Wagner G, Fenchel K, Back W, Schulz A, Sachse MM. Leukemia cutis: epidemiology, clinical presentation, and differential diagnoses. J Dtsch Dermatol Ges. 2012;10(1):27-36. doi:10.1111/j.1610-0387.2011.07842.x
    8. Mondì V, Piersigilli F, Salvatori G, Auriti C. The skin as an early expression of malignancies in the neonatal age: a review of the literature and a case series. Biomed Res Int. 2015;2015:809406. doi:10.1155/2015/809406
    9. Cho-Vega JH, Medeiros LJ, Prieto VG, Vega F. Leukemia cutis. Am J Clin Pathol. 2008;129(1):130-142. doi:10.1309/WYACYWF6NGM3WBRT
    10. Adjei S, Temiz LA, Miller AC, Sadek R, Grush AE, Tyring SK. Leukemia cutis in skin of color. J Drugs Dermatol. 2023;22(7):687-689. doi:10.36849/JDD.7020

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