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Year : 2014  |  Volume : 59  |  Issue : 4  |  Page : 424
Paraphenylenediamine-induced cutaneous pseudolymphoma

1 Department of Dermatology, Skin, Hair and Laser Clinic, Bangalore, Karnataka, India
2 Dr. Elizabeth's Skin and Hair Clinic, Bangalore, Karnataka, India
3 Department of Dermatology, St John's Medical College and Hospital, Bangalore, Karnataka, India

Date of Web Publication27-Jun-2014

Correspondence Address:
Fiona F Sequeira
Department of Dermatology, Skin, Hair and Laser Clinic, Bangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.135562

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How to cite this article:
Sequeira FF, Jayaseelan E, Stephen J. Paraphenylenediamine-induced cutaneous pseudolymphoma. Indian J Dermatol 2014;59:424

How to cite this URL:
Sequeira FF, Jayaseelan E, Stephen J. Paraphenylenediamine-induced cutaneous pseudolymphoma. Indian J Dermatol [serial online] 2014 [cited 2022 Jun 29];59:424. Available from:


A 45 year-old man presented with itchy red nodular lesions over the moustache area of 2 months duration. On probing into his medical/personal history, we found that he had no complaints of fever, regular intake of medication, history of recent travel, localized trauma, or insect bites. The patient had been dyeing his moustache once a month for over two months. On local examination, the affected area showed two erythematous asymptomatic nodules over the right lateral aspect [Figure 1] and a single erythematous asymptomatic plaque over the left lateral aspect of the upper lip. [Figure 2]. A systems review and systemic examination were normal.
Figure 1: Two erythematous nodules over the right lateral aspect of the moustache area

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Figure 2: A single erythematous nodule over the left lateral aspect of the moustache area

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A skin biopsy was done and the histopathological examination revealed atrophy of the epidermis, grenz zone with an underlying dense nodular dermal lymphoid infiltrate [Figure 3] extending to the subcutaneous tissue and scattered eosinophils [Figure 4] and [Figure 5].
Figure 3: Atrophic epidermis, with an underlying dense, nodular dermal lymphoid infilterate H and E, ×40

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Figure 4: Predominantly lymphocytic infiltrate, many of them showing convoluted nuclei. Scattered eosinophils are also seen. H and E, ×400

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Figure 5: Infiltrate involving the subcutaneous tissue. H and E, ×100

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T-cell receptor gene analysis on DNA extracted from the skin using polymerase chain reaction did not identify the presence of a clonal population of cells. Subsequently, a patch testing for 1% paraphenylenediamine showed a 2+ positive reaction [Figure 6]. However, a immunohistochemistry was not done in our case as the patient did not want to undergo any further investigations.
Figure 6: Patch testing for 1% paraphenylenediamine showed a 2 + positive reaction

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Based on the above findings, a diagnosis of lymphomatoid contact dermatitis to paraphenylenediamine was made. The patient was advised to avoid use of hair dye. The lesions completely subsided with topical steroids. No relapse was seen on subsequent follow-ups.

Pseudolymphoma is a process that simulates lymphomas, primarily histologically but sometimes clinically, which at the time of diagnosis appears to have a benign biologic behavior and does not satisfy criteria for malignant lymphoma. [1]

Lymphomatoid contact dermatitis is a chronic persistent allergic contact dermatitis that forms part of the spectrum of pseudolymphomas. [2] Two types have been described [3]: (a) A localized form, characterized by single or multiple lesions affecting only the area of contact with the sensitizer; (b) an eczematous/lichenoid form, evolving into erythroderma, which does not necessarily improve when the sensitizer is removed and/or appropriate therapy initiated. [2] The precise immunological mechanism behind lymphomatoid contact dermatitis remains unclear; but it has been hypothesized that it may result from the stimulation of lymphocytes by antigen recognition to undergo transformation into blast cells. [4] A wide array of allergens have been reported to cause lymphomatoid contact dermatitis. They include paraphenylenediamine, gold, nickel, zinc, formaldehyde, isopropyl-diphenylenediamine, ethylenediamine, para-tertyl- butyl phenol resin, and cobalt naphthenate. [4]

There are many clinical and histological differences between pseudolymphoma and lymphoma [5],[6] [Table 1]. However, in most cases, it is histopathologically impossible to differentiate intraepidermal collections of mononuclear cells from the Pautrier's microabscesses of mycosis fungoides. In our case, the histology was compatible with lymphoma, but the presence of spongiotic microvesiculation together with the clinical aspects of the lesions led us to suspect that we were dealing with a lymphomatoid contact dermatitis. This was confirmed with patch tests and the resolution of the lesions once contact with the causal agent had been withdrawn. Investigations using immunohistochemical and molecular biological (T-cell receptor rearrangement) techniques may also be helpful.
Table 1: Clinical and histological differences between pseudolymphoma and lymphoma

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In PPD-induced pseudolymphoma, avoidance of PPD containing products and cross reacting substances (PABA, azo dyes, thiazide diuretics, ester containing anesthetics ex: tetracaine, procaine, benzocaine, etc.) and treatment with topical corticosteroids leads to complete resolution of the lesions. [7] On occasion, they have been reported to develop into authentic lymphomas or leukaemias. [8] Hence, a close watch must be kept on these patients.

Various other reactions known to occur due to hair dye use include acute allergic contact dermatitis, contact urticaria, lichenoid dermatitis, contact vitiligo, and rarely anaphylaxis. [9]

   References Top

1.Polysangam T, Breneman DL, Mutasim DF. Cutaneous pseudolymphoma. J Am Acad Dermatol 1998;38 (6 Pt 1):877-95.  Back to cited text no. 1
2.Ecker RI, Winkelmann RK. Lymphamatoid contact dermatitis. Contact Dermatitis 1981;7:84-93.  Back to cited text no. 2
3.Sertoli A. Dermatology occupational and environmental allergy. 1 st ed. Roma: 11 Pensiero scientifico Editore; 1991. p. 128-30.  Back to cited text no. 3
4.Evans AV, Banerjee P, McFadden JP, Calonje E. Lymphomatoid contact dermatitis to para-tertyl-butyl phenol resin. Clin Exp Dermatol 2003;28:272-3.  Back to cited text no. 4
5.Ackerman AB, Breza TS, Capland L. Spongiotic simulants of mycosis fungoides. Arch Dermatol 1974;109:218-20.  Back to cited text no. 5
6.Kerl H, Fink-Punchess R, Cerroni L. Diagnostic criteria of primary cutaneous B-cell lymphomas and pseudolymphomas. Keio J Med 2001;50:269-73.  Back to cited text no. 6
7.Redlick F, DeKoven J. Allergic contact dermatitis to paraphenylenediamine in hair dye after sensitization from black henna tattoos: A report of 6 cases. CMAJ 2007;176:445-6.  Back to cited text no. 7
8.Abraham S, Braun RP, Matthes T, Saurat JH. A follow-up: Previously reported apparent lymphomatoid contact dermatitis, now followed by T-cell prolymphocytic leukaemia. Br J Dermatol 2006;155:633-4.  Back to cited text no. 8
9.Fukunaga T, Kawagoe R, Hozumi H, Kanzaki T. Contact anaphylaxis due to para-phenylenediamine. Contact Dermatitis 1996;35:185-6.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]

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[Pubmed] | [DOI]


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