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Case Reports

Abstract

A 61-year-old woman with psoriatic arthritis presented with several days of redness
and swelling involving the nasal dorsum and bilateral ear lobules. She was initially treated
for presumed rosacea with azelaic acid and doxycycline, without improvement. Her
medications included hydroxychloroquine and a recent prednisone taper. Clinical
examination revealed pink to violaceous, non-tender nodules coalescing on the nasal tip
and dorsum, with discrete nodules on each ear lobule, lacking scale or ulceration. A punch
biopsy of the left ear lobule demonstrated a dense, diffuse infiltrate of small, mature
lymphocytes within the reticular dermis and subcutis. Immunohistochemistry confirmed a
B-cell phenotype with co-expression of CD5 and CD20, consistent with chronic lymphocytic
leukemia (CLL), and showed no evidence of granulomatous inflammation or
epidermotropism. These findings established a diagnosis of leukemia cutis. This case
illustrates a rare rhinophymatous presentation of leukemia cutis, a manifestation that may
clinically mimic granulomatous rosacea or other inflammatory dermatoses of the central
face. While cutaneous involvement in CLL is uncommon, its clinical spectrum is broad and
can be easily mistaken for benign conditions, particularly when facial structures such as the
nose and ears are involved. This underscores the importance of biopsy in patients with
persistent or treatment-refractory facial nodules, especially in the setting of underlying or
suspected hematologic disease. Dermatologists and dermatopathologists should remain
alert to this unusual presentation, as accurate diagnosis relies on histopathologic
assessment with immunophenotyping, which is critical for guiding appropriate oncologic
evaluation and management.