A 10-month-old Caucasian boy presented to the dermatology clinic for evaluation of a persistent diaper rash. His mother reported that the eruption began at approximately 4 months of age, involving the gluteal cleft, perineum, and bilateral inguinal folds. His axillae were also affected bilaterally. His mother described the eruption as red, raw, painful, and pruritic; affected areas would bleed with even slight manipulation.The patient had previously been diagnosed by his pediatrician with a variety of conditions including contact dermatitis, seborrheic dermatitis, staphylococcal infection, perianal streptococcal infection, and candidiasis. Skin cultures had previously returned positive for methicillin-resistant Staphylococcus aureus and Streptococcus, but despite multiple rounds of oral antibiotics, the eruption persisted and improved only minimally while on therapy. Other treatments including azole and polyene antifungals, as well as low-potency topical steroids, were ineffective. Similarly, use of hypoallergenic soaps, detergents and wipes, and trials of various diaper brands produced no improvement in the eruption. The patient had no history of fevers, fatigue, weight loss, or problems with growth and development. His past medical history was notable only for a mild iron deficiency anemia and gastroesophageal reflux.A complete skin examination revealed erythematous, friable plaques with weeping erosions and scattered papules in the bilateral inguinal folds, gluteal cleft, and bilateral axillary vaults (Figures 1 and 2). Pinpoint bleeding was observed even with light manipulation, and the areas were tender to palpation. The remainder of the patient's skin appeared unremarkable, and he did not demonstrate lymphadenopathy or hepatosplenomegaly. A skin culture and punch biopsy of the upper left gluteal cleft was obtained.Skin culture returned positive for mixed gram-positive flora. Histologic examination revealed a dense band-like infiltrate within the superficial dermis obscuring the dermal-epidermal junction, consisting of mixed inflammation with eosinophils, lymphocytes, plasma cells, and occasional neutrophils (Figure 3A). However, the predominant cell in this infiltrate was larger with 834277C PJXXX10.

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma (CTCL) and often has an indolent course, particularly for patients presenting with early-stage (patch/plaque) disease. Early-stage MF is primarily managed with skin-directed therapies. Topical mechlorethamine hydrochloride (nitrogen mustard [NM]) gel has increased tolerability compared to prior NM formulations, though contact dermatitis remains a common side effect. The addition of topical steroids can improve tolerability while maintaining the efficacy of NM gel. Real-world experience supports that NM gel also has a role in combination therapy and as adjunctive therapy in advanced-stage disease. Here we review factors that may influence patient selection for use of NM gel, including MF variants, special patient populations, cost effectiveness, and impact on quality of life for patients with MF.

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