This case series discusses 3 patients with long-standing eczematous or psoriasiform dermatitis, demonstrated by multiple biopsies. Following off-label treatment with dupilumab, all 3 patients had clinical expansion of disease, with histopathologic features consistent with cutaneous T-cell lymphoma (CTCL) on subsequent biopsy. We postulate that this expansion likely was secondary to an exacerbation of extant CTCL following exposure to dupilumab. A proposed mechanism of promotion of CTCL is based on the functional increase in IL-13 available for binding at the upregulated IL-13 receptor (IL-13R) α2 site on cells, following blockade of the α1 receptor with dupilumab. This progression merits further investigation.

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A 59-year-old white man with a history of Sydenham's chorea received a mitral valve prosthesis in 1962. He sustained an anterolateral myocardial infarction in 1983. In 1984, he received a heart transplant. To prevent heart rejection, he was initially treated with cyclosporine 12 mg/kg/day and prednisone 90 mg b.i.d. In 1987, azathioprine 100 mg daily was added. In 1989, at the time of our evaluation, his medications included cyclosporine 80 mg b.i.d., prednisone 10 mg b.i.d., and azathioprine 75 mg/day. Since his heart transplant surgery he had not taken any thiazide medication. The patient noted a lesion on his right thigh; the lesion appeared in 1986, 2 years after his heart transplant. On examination in 1989, the lesion was a 2 cm wide annular plaque with a shiny atrophic center and raised border. Both the clinical appearance and pathology were consistent with a diagnosis of porokeratosis of Mibelli. No family history of porokeratosis was elicited.

A 52-year-old black man was admitted to the county medical center for drug detoxification. He abused many drugs during the 30 years before admission, including intravenous heroin and cocaine. He also admitted to "skin popping" cocaine during the 3 years before admission. A dermatology consultation was requested for evaluation of multiple lesions of the legs of 2 years' duration.

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