Oral and topical retinoids are widely used for treating
Mycosis Fungoides (MF), the most common form of
cutaneous t-cell lymphoma (CTCL).1,2 While the retinoid-
X-receptor-selective bexarotene is the only topical retinoid
approved for MF, other retinoids such as tretinoin have
also been used.3 As with all topical retinoids, both bexarotene
and tretinoin typically cause mild-to-moderate local irritation.4,5
This irritation may be reduced by alternating retinoid treatment
with mid-potency topical corticosteroid treatment. Use of topical
steroids may also bring synergistic benefits in conjunction
with retinoids.6 An added benefit of combination treatment
arises from the fact that steroid-associated skin atrophy can potentially
be mitigated by concomitant retinoid usage.7
Retinoids under occlusion have been tried used in various
settings other than MF. Stam-Posthuma et al attempted unsuccessfully
to treat nevi with tretinoin and/or hydrocortisone under
occlusion.8 Watson et al reported use of 0.025% all-trans retinoic
acid under occlusion to treat photoaging.9 Fisher et al explored
tretinoin under occlusion for prevention of photodamage.10
We present the first report of MF treated with combined steroid
and retinoid wraps. A 76-year-old Caucasian male with folliculotropic
MF presented to an academic outpatient dermatology
clinic for further management of skin-directed therapy. Physical
exam revealed scaly, erythematous papules and plaques with
follicular prominence distributed over the trunk and extremities.
Fevers, night sweats, and lymphadenopathy were absent.
Flow cytometry showed an elevated CD4:CD8 ratio of approximately
30:1. Treatments at time of presentation included topical
triamcinolone and clobetasol twice daily to affected areas on the
trunk and limbs, as well as interferon alfa 2b three million units
subcutaneously biweekly, and extracorporeal photopheresis
(ECP) every other week. The systemic treatment regimen did
not change during the duration of the case reported here.
At time of presentation most cutaneous lesions were responding
to therapy, with the exception of a few resistant
raised firm scaly erythematous plaques on the chest, arms and legs.
To address this, a new regimen was tried initially
on a single resistant plaque on the right calf (Figure 1). An
occlusive Unna wrap was applied to the right calf over a layer
of 0.1% tazarotene gel and a layer of 0.1% triamcinolone
ointment. The initial wrap stayed in place until the patient’s
follow up examination two weeks later. At that time the resistant
plaque showed decreased erythema and scaling with
no local or systemic side effects. Despite the good initial
response, the patient chose to switch over to a more convenient
and affordable regimen of 0.1% tretinoin and 0.05%
clobetasol under plastic-wrap occlusion to be applied at
home. Specifically, the patient applied a fresh plastic-wrap
dressing each night, alternating tretinoin wraps with clobetasol
wraps. Follow up appointments at two-week intervals
demonstrated continued improvement in the patient’s resistant
folliculotropic MF plaque. Treatment was continued for
22 more weeks without any adverse side effects or patient
complaints. By that time the patient’s right lower extremity
plaque had become significantly flatter and smoother, similar
in appearance to his non-resistant lesions (Figure 2). Based
on this response, other resistant plaques were subsequently
treated in the same way.
Skin-directed MF therapies typically include steroids,11
retinoids,1 mechlorethamine,12 phototherapy,13 and radiotherapy.
14 Folliculotropic MF is generally considered to be more
resistant to topical therapies.15 If MF plaques are resistant to
these topical therapies, systemic treatment may be considered.
Systemic MF / CTCL treatments include photopheresis,16
oral retinoids,2 histone deacetylase inhibitors,17 denileukin
diftitox,18 and ultimately conventional chemotherapy.
The present case demonstrated tolerability and efficacy of
topical retinoids under occlusion combined with topical
