R. Hal Flowers, MD

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Erythematous Dermal Facial Plaques in a Neutropenic Patient

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THE DIAGNOSIS: Neutrophilic Eccrine Hidradenitis

A biopsy from the left preauricular cheek demonstrated dermal neutrophilic inflammation around eccrine coils with focal necrosis (Figure). No notable diffuse dermal neutrophilic infiltrate was present, ruling out Sweet syndrome, and no notable interstitial neutrophilic infiltrate was present, making cellulitis and erysipelas less likely; panculture of tissue also was negative.^1,2 Atypical cells in the deep dermis were positive for CD163 and negative for CD117, CD34, CD123, and myeloperoxidase, consistent with a diagnosis of neutrophilic eccrine hidradenitis (NEH) and reactive histiocytes.³Treatment with oral prednisone resulted in rapid improvement of symptoms.

A, Histopathology showed a neutrophilic infiltrate surrounding and extending into intact eccrine coils. B, Within the same specimen, other areas demonstrated destruction of the eccrine coils in areas of dense neutrophilic inflammation (H&E, original magnifications ×20).

Neutrophilic eccrine hidradenitis is a rare reactive neutrophilic dermatosis characterized by eccrine gland involvement. This benign and self-limited condition presents as asymmetric erythematous papules and plaques.² Among 8 granulocytopenic patients with neutrophilic dermatoses, 5 were diagnosed with NEH.⁴Although first identified in 1982, NEH remains poorly understood.² Initial theories suggested that NEH developed due to cytotoxic substances secreted in sweat glands causing necrosis and neutrophil chemotaxis; however, chemotherapy exposure cannot be linked to every case of NEH. Neutrophilic eccrine hidradenitis can be extremely difficult to differentiate clinically from conditions such as cellulitis and Sweet syndrome.

A patient history can be helpful in identifying triggering factors. Neutrophilic eccrine hidradenitis most commonly is associated with malignant, drug-induced, or infectious triggers, while Sweet syndrome has a broad range of associations including infections, vaccines, inflammatory bowel disease, pregnancy, malignancy, and drug-induced etiologies (Table).¹On average, NEH presents 10 days after chemotherapy induction, with 70% of cases presenting after the first chemotherapy cycle.⁵ Bacterial cellulitis or erysipelas have an infectious etiology, and patients may report symptoms such as fever, chills, or malaise. Immunosuppressed patients are at greater risk for infection; therefore, clinical signs of infection in a granulocytopenic patient should be addressed urgently.

Abbreviations: AML, acute myeloid leukemia; CML, chronic myelogenous leukemia; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; G-CSF, granulocyte colony-stimulating factor; GI, gastrointestinal; GU, genitourinary; IBD, inflammatory bowel disease; NEH, neutrophilic eccrine hidradenitis; NSAID, nonsteroidal anti-inflammatory drug; PCV, pneumococcal conjugate vaccine; TMX, tamoxifen; URI, upper respiratory infection; WBC, white blood cell count.

Physical examination may have limited value in differentiating between these diagnoses, as neutrophilic dermatoses notoriously mimic infection. Cutaneous lesions can appear as pruritic or tender erythematous plaques, papules, or nodules in these conditions, though cellulitis and erysipelas tend to be unilateral and may have associated purulence or inflamed skin lymphatics. Given the potential for misdiagnosis, approaching patients with a broad differential can be helpful. In our patient, the differential diagnosis included Sweet syndrome, NEH, bacterial cellulitis, erysipelas, leukemia cutis, sarcoid, and eosinophilic cellulitis.

Leukemia cutis refers to the infiltration of neoplastic leukocytes in the skin and often occurs in patients with peripheral leukemia, most often acute myeloid leukemia or chronic lymphocytic leukemia. Patients with leukemia cutis often have a worse prognosis, as this finding signifies extramedullary spread of disease.⁶ Clinically, lesions can appear similar to those seen in our patient, though they typically are not symptomatic, can be nodular, tend to exhibit a violaceous hue, and occasionally may be hemorrhagic. Wells syndrome (also known as eosinophilic cellulitis) is an inflammatory dermatosis that presents as painful or pruritic, edematous and erythematous plaques.^7,8 A green hue on resolution is present in some cases and may help clinicians differentiate this disease from mimickers.⁷ Often, eosinophilic cellulitis is misdiagnosed as bacterial cellulitis and treated with antibiotics. The presence of systemic symptoms such as fever or arthralgia is more typical of bacterial cellulitis, erysipelas, eosinophilic cellulitis, or Sweet syndrome than of NEH.¹ Additionally, inflammatory markers (ie, C-reactive protein) and white blood cell counts tend to be elevated in bacterial cellulitis and Sweet syndrome, while leukopenia often is seen in NEH.

Histopathology is crucial in distinguishing these disease etiologies. Neutrophilic eccrine hidradenitis is diagnosed by the characteristic neutrophilic infiltrate and necrosis surrounding eccrine glands and coils. There also may be occasional intraductal abscesses and syringosquamous metaplasia of the sweat glands along with fibrosis of the adjacent dermis. In contrast, histologic sections of Sweet syndrome show numerous mature neutrophils infiltrating the dermis with marked papillary dermal edema. The histopathology of bacterial cellulitis and erysipelas is less specific, but common features include dermal edema, lymphatic dilation, and a diffuse neutrophilic infiltrate surrounding blood vessels. Pathogenic organisms may be seen on histopathology but are not required for the diagnosis of bacterial cellulitis or erysipelas.² Additionally, blood and tissue culture can assist in identification of both the source of infection and the causative organism, but cultures may not always be positive.

Comparatively, the histopathologic features of eosinophilic cellulitis include dermal edema, eosinophilic infiltration, and flame figures that form when eosinophils degranulate and coat collagen fibers with major basic protein. Flame figures are characteristic but not pathognomonic for eosinophilic cellulitis.⁷ The histopathology of leukemia cutis varies based on the leukemia classification; generally, in acute myeloid leukemia the infiltrate is composed of neoplastic cells in the early stages of development that are positive for myeloid markers such as myeloperoxidase. Atypical and immature granulocytes within the leukocytic infiltrate differentiate this condition from the other diagnoses. Treatment may entail chemotherapy or radiotherapy, and this diagnosis generally carries the worst prognosis of all the conditions in the differential.⁶

Differentiating between these conditions is important in guiding treatment, especially in patients with febrile neutropenia. Unnecessary steroids in immunosuppressed patients can be dangerous, especially if the patient has an infection such as bacterial cellulitis. Furthermore, unwarranted antibiotic use for noninfectious conditions may expose patients to substantial side effects and not improve the condition. Neutrophilic eccrine hidradenitis typically is self-limited and treated symptomatically with systemic corticosteroids and nonsteroidal anti-inflammatory drugs.³ Sweet syndrome often requires a longer course of oral steroids. Leukemia cutis worsens as the leukemia advances, and treatment of the underlying malignancy is the most effective treatment.⁹

Early and accurate recognition of the diagnosis can prevent harmful diagnostic delay, unnecessary antibiotic use, or extended steroid taper in neutropenic patients. Appreciating the differences between these diagnoses can assist clinicians in investigating and tailoring a broad differential to specific patient presentations, which is especially critical when considering common mimickers for life-threatening conditions.

References

Nelson CA, Stephen S, Ashchyan HJ, et al. Neutrophilic dermatoses. J Am Acad Dermatol. 2018;79:987-1006. doi:10.1016/j.jaad.2017.11.0642
Srivastava M, Scharf S, Meehan SA, et al. Neutrophilic eccrine hidradenitis masquerading as facial cellulitis. J Am Acad Dermatol. 2007;56:693-696. doi:10.1016/j.jaad.2006.07.032
Copaescu AM, Castilloux JF, Chababi-Atallah M, et al. A classic clinical case: neutrophilic eccrine hidradenitis. Case Rep Dermatol. 2013; 5:340-346. doi:10.1159/000356229
Aractingi S, Mallet V, Pinquier L, et al. Neutrophilic dermatoses during granulocytopenia. Arch Dermatol. 1995;131:1141-1145.
Cohen PR. Neutrophilic dermatoses occurring in oncology patients. Int J Dermatol. 2007;46:106-111. doi:10.1111/j.1365-4632.2006.02605.x
Wang CX, Pusic I, Anadkat MJ. Association of leukemia cutis with survival in acute myeloid leukemia. JAMA Dermatol. 2019;155:826. doi:10.1001/jamadermatol.2019.0052
Chung CL, Cusack CA. Wells syndrome: an enigmatic and therapeutically challenging disease. J Drugs Dermatol. 2006;5:908-911.
Räßler F, Lukács J, Elsner P. Treatment of eosinophilic cellulitis (Wells syndrome): a systematic review. J Eur Acad Dermatol Venereol. 2016;30:1465-1479. doi:10.1111/jdv.13706
Hobbs LK, Carr PC, Gru AA, et al. Case and review: cutaneous involvement by chronic neutrophilic leukemia vs Sweet syndrome: a diagnostic dilemma. J Cutan Pathol. 2021;48:644-649. doi:10.1111 /cup.13925

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Author and Disclosure Information

From the Department of Dermatology, University of Virginia, Charlottesville. Dr. Gradecki also is from the Department of Pathology.

The authors report no conflict of interest.

Correspondence: Erica J. Mark, MD, 1215 Lee St, Charlottesville, VA 22903 ([email protected]).

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