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Most times, a skin rash is a skin rash. But sometimes, if the skin condition comes out of nowhere, and if it does not respond to treatment, it could be a sign that something else is going on.
And that something could be lymphoma.
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My guest today is Dr. Peter Lio, a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine.
He received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. While at Harvard, he received formal training in acupuncture.
Dr. Lio has written a textbook on Integrative Dermatology and has published over 100 papers.
Join us as we discuss whether your skin rash could be a sign of lymphoma.
Have you ever experienced a skin rash being a sign of something else? Tell me about it in the comments!
In this episode:
- Can a rash start off as one thing, but become something else?
- How can you tell whether a rash might be an indication of something else?
- Why swollen lymph nodes should be assess by your doctor
- What is a lipoma?
- Could chronic hives be a sign of cancer?
Quotes
“Lipomas are really, really common. They're basically little fatty lumps. They're just a little bit of extra fat tissue, it's usually just under the skin.” [16:39]
“There are also a whole bunch of signs that are called paraneoplastic signs. These are things that are associated with cancer. And again, they're all pretty rare.” [2:02]
Links
Healthy Skin Show ep. 001: How to Protect & Strengthen Your Skin Barrier w/ Dr. Peter Lio
Healthy Skin Show ep. 037: Nickel Allergy And Eczema w/ Dr. Peter Lio
Healthy Skin Show ep. 104: Topical B12 For Skin Rashes w/ Dr. Peter Lio
Healthy Skin Show ep. 136: Alternative Solutions For Rosacea w/ Dr. Peter Lio
Healthy Skin Show ep. 176: Dealing With Recurrent Skin Infections w/ Dr. Peter Lio
Follow Dr. Lio on Twitter | Facebook
216: Could Your Rash Be A Sign Of Lymphoma? w/ Dr. Peter Lio FULL TRANSCRIPT
Jennifer: Hey, Dr. Lio. Thank you so much for coming back to the show. You know you're one of my favorite guests, and you are a favorite guest of the listeners because of how empathetic and caring and creative you are as well. I'm excited to have this conversation today because it's a little more on the serious side, a little more serious, but really, really important. So, we're going to be talking about when skin issues might be a sign of something more serious like lymphoma. And if you didn't know that that was a possible, I guess a symptom almost. Let's start with, do you have a case example that you could share with us where maybe someone presents with some sort of rash, whether it's psoriasis or eczema or whatever, but it ends up becoming something else?
Dr. Lio: Absolutely. It's really important I think to bringing this out because one of the things that gets a lot of medical students interested in doing dermatology, present company included, I was interested in it as well, is because part of our job is to look at the skin and be able to use that as a window, so to speak, to the body. And it is really difficult and it was so cool. I remember being a medical student and just being incredibly impressed that the seasoned cardiology professor who had been around for a long time and was gray at the temples and would have a patient of his, and it would say, I don't know what's going on on the skin. And the young dermatologist walked in and was like, oh, this is this, don't worry. And I was like, wow, they are like a Jedi. How did they know what was going on? They could see it. That's what it means to train in an area and become an expert in a subject area.
Dr. Lio: So we often think about the chronic things that we do treat and the common things that people know about acne and rosacea and things, but the interesting part of derm is looking at those what we call cutaneous manifestations of systemic disease. And there are whole books on them. And in fact, there are also a whole bunch of signs that are called paraneoplastic signs. These are things that are associated with cancer. And again, they're all pretty rare. Many of them are very, very rare. Some of them are even kind of controversial. Do they really exist? Are they just some artifact? Are they just a historical footnote? And we wrote a big article a couple of years ago, my co-chief resident and I after we finished residency kind of talking about all of them, and it was really, really insightful because sometimes you realize, gosh, well, how can you tell the difference.
Dr. Lio: So, a case that I remember really well back when I was still in Boston, this is more than a decade ago now, I had this really nice lady who had terrible, terrible hand eczema. They were dry, they were cracked, and we did all sorts of stuff. She had seen a few people and had just minimal improvement, I did all of my tricks, and I just really couldn't get her much better. She was the nicest patient, and she was really suffering. They would bleed and crack. This carried on for three, four, five months, we tried a whole bunch of different things. And finally, one day she came in and I said, “Are you feeling okay? What's wrong?” She was kind of sitting funny, she looked uncomfortable. And it turned out that her belly didn't feel good. And I did a little bit of an exam, but I have to confess, she was a bit heavy set and I couldn't tell much, I said, “You know, I'm just worried about you, let's get you checked out.”
Dr. Lio: Sure enough, she had lymphoma. And the lymphoma was pretty aggressive and it was kind of rapidly growing in her belly, but they treated the lymphoma, and her skin cleared up. So we think that, in retrospect I'm like, gosh, it was kind of a funny one. It was super dry and scaly. It probably was a paraneoplastic sign. Now, I don't want to scare everybody, these are super duper, duper rare, but in situations where things aren't getting better, where we're stuck, that's why you'll often see us, and that's why it's good to see a medical doctor because we have that training.
Dr. Lio: People sometimes rip on dermatologists, you guys aren't real doctors. I know we don't seem like it sometimes, if we're just popping pimples or something, but we really are. We really went through medical school and we really spent time in the oncology unit and all those different things. And that shapes you, you get a different perspective than if you, estheticians know a lot about skin and they probably know more about day to day skincare stuff and products than I do. They could beat me because that's their world, but they never spend time in the cancer ward, they never spend time post-surgical units. So, that's okay. It's different specialists and different expertise. So I think this was a situation where that kind of training served me. And I said, we better check this out. And of course, I didn't do the workup. I sent her back to her primary doctor saying I'm worried about her, and then we were able to make the diagnosis.
Jennifer: The one case that I can also share is that I worked with a woman who had this chronic eczema and she also had swollen lymph nodes. And lymph nodes being swollen can be a sign for a number of things. And I just said, you know, I really think you need to go get that checked. And she felt like her family doctor wasn't really taking it seriously. And I said, no, no, no, I really think you got to keep pushing. And lo and behold, it turned out that she did have lymphoma. And I said, listen, you need to address that. So when you find out that you have lymphoma, no matter what the skin manifestation is, the lymphoma takes precedence. My understanding and my sense would be lymphoma is more important than focusing on how do I get rid of the rash because like you said, it was actually a sign of an underlying problem. And you had said that the woman's hand eczema actually went away after addressing.
Dr. Lio: It was gone, it was totally gone. And that is such a good point because I would say there are two areas where I'm really thinking about this kind of situation where my spider sense goes off, if you will. The first is new onset, a rapid sudden onset of something. So in a way, the easier patient is the patient who sees me as a young adult or even an older adult that says, I've had eczema whole life, or I've had psoriasis for many years. You feel much better about it. You're like, okay, this is your protoplasm, this is sort of what we got to deal with, or I have a strong family history of this. That's easier.
Dr. Lio: The more concerning cases like this patient was, I never had any skin problems my whole life. Maybe I had some acne as a teenager and then here I am in my 40s, and suddenly, my hands are the worst hand eczema that everyone's ever seen. You're like the fourth doctor to look at it and no one can fix me. Those kinds of situations are going to make us say, we got to think about it. And the other of course is if we can't get somebody better. And I think one of the things we see a lot in my area of focus, atopic dermatitis, is that cutaneous T-cell Lymphoma, CTCL, sometimes called mycosis fungoides is a kind of skin lymphoma. The good news is, for the most part, it's actually not that dangerous. Most of the patients who have a mild form of it actually do fine. It's not as scary as it sounds. But it often takes years to diagnose, and many biopsies and many tests, it's one of these tricky things.
Dr. Lio: And the weirdest thing is, the more specialized my clinic has gotten where I'm seeing these really tough cases, the more of it I'm seeing. I'm like, boy, you failed everything, all of our tricks, boy, your skin looks terrible. I'm like, I'm going to do another biopsy, I'm going to do flow cytometry of your blood, I'm going to figure out what else is going on. And then we've had a flurry of these cases where I'm like, actually, I'm so sorry, the reason you're not getting better is it hasn't been eczema, it's this other thing. And then we send them to a CTCL center and an expert who can get them through it. And many patients do very, very well.
Dr. Lio: But it is something different, it can mimic. And I think we see that with eczema, we can see that with psoriasis. Of course, we know on the nipple area, the breast rashes are also kind of concerning. They can look like nipple eczema, which is not an uncommon thing, but there is a type of breast cancer that can make this kind of inflammatory appearance, sometimes they call it inflammatory ductal carcinoma, and you can actually see a change in the breast area or the nipple area.
Dr. Lio: Again, I don't want to alarm people 99 times out of 100, maybe even more, it's just nipple eczema. So what would I tell my patient if they say, hey, I have a rash on my nipple, I looked it up on the internet and they said, be afraid of breast cancer. I said, okay, don't worry, we'll take a look, it looks fine, let's try the treatment. And if the treatment, if it goes away, well, then we know it's not cancer because the cancer doesn't just clear right up typically speaking. If it's being stubborn or it's not being persistent not responding like we hope then, I'm going to say, we're going to take a biopsy, we're going to go to the next level.
Jennifer: So when you say if it doesn't respond to treatment, does that essentially mean like it doesn't respond to, I mean, steroid creams and steroids tend to be like some of the first options. Would that be one possible sign that it wouldn't respond to a steroid?
Dr. Lio: Definitely. Steroids are a little tricky because they do help so many things. And one of my teachers used to always say, if you remember the CHOP regimen for lymphomas and leukemias, they're called CHOP. The P in CHOP, it stands for different things, but the P stands for prednisone. So steroids actually do have to some degree, they can be used to fight cancers. So, they're not the best bellwether because they kind of help everything. And in fact, one of the things we'll say too is kind of everything can get better with steroids temporarily, including infection. Sometimes you can put steroids on an infection and kind of mask it. So yes, but I think it is a little bit of a longer picture, it's the overall treatment response.
Dr. Lio: So yeah, maybe they put a steroid on and it got better that day, that doesn't necessarily make me feel better if it flares up two days later and next week, and it's worse than ever, then I might say something as fishy.
Jennifer: And so, you had mentioned that this can be very difficult to pick up. Are there certain red flags, signs, when you're assessing a patient, so if someone's listening to this and they're like, oh no, I have these symptoms and I never even told my dermatologist about these, is there anything that someone, I mean, I think that swollen lymph nodes are a red flag that should be assessed by a medical doctor, but in your experience in practice, what are some red flags signs that might even be outside of the skin that people might not put two and two together about?
Dr. Lio: Definitely. I think there's a number of things that I would ask about, sort of the B symptoms. Are you losing weight that you're not trying to lose? Suddenly it's like, boy, I wasn't gaining weight, which I was first happy about, but now I'm losing weight and I can't seem to put weight on. Are you having night sweats? Are you having trouble with, in terms of things like falling asleep or getting up a lot, having issues? Are you feeling like you're feeling nauseated? Are you having pain in your body in different places? These are some of the softer signs that we can kind of put together. Sometimes people can even have fevers as a sign that there's something brewing.
Dr. Lio: So we're kind of asking about overall health, we're asking about some of these points. But I would argue, by definition, these can be a little tricky. So what we'll do if we're not sure is we'll say, just listen, I want you to make sure you see your primary doctor, get your physical, make sure all of your screening is up to date, your routine screening, because that's really, really important, especially if there's something going on. And so, it can be difficult and we can easily miss these things for a while.
Jennifer: So, in these instances where someone does actually discover that they have a lymphoma, and I'm sure it's really hard to tell a patient that something like that is going on. I know when my dad was alive and he used to have to tell a patient like, hey, your CT Scan shows that you, or MRI shows that you have some sort of tumor or something going on, it was a hard conversation to have. Is there something if someone has found this out recently that you could, some wisdom that you could impart to them? If someone told me I had lymphoma, honestly, I'd probably be freaking out.
Dr. Lio: It is scary. Even for these less severe ones like we were saying, the cutaneous T-cell lymphoma, actually for most patients is okay, they're going to do all right. The prognosis is generally pretty good for the milder cases. But you're right, I think we really need to give patients a beat to kind of let it sink in. A lot of times what I found is that no matter what I say for the rest of the visit, it sort of doesn't stick. They're just kind of in shock.
Dr. Lio: So usually if I feel like that's going that way, I'll kind of say my piece. I'll give some printed stuff and I'll say, listen, let's talk tonight, why don't you call me when you get home, because some people are like, oh my gosh, I'm so sorry, I just wasn't myself. It's like, yeah, you're a little bit of shock, and it's really hard to pay attention to something or take notes on it. So it's like, let's follow up. We'll talk by phone, you're relaxed. And sometimes it's also really nice to have a family member around too because the other person can sort of help just sort of contain the environment and ask the questions. But a lot of times, I just really have to say, we're going to talk again very soon, take a few days to digest it.
Dr. Lio: And the good thing is, at least from my line of work, and we're lucky, dermatology we're kind of lucky because we catch stuff pretty early, we're catching stuff with these other signs. A lot of times it's not a CT scan, I wouldn't have that in front of me. So I'm going to be making this diagnosis really early. So, I get to sort of say, listen, I don't know but it's possible, it's not that bad, and we don't know yet, so, let's keep optimistic. We caught it. We know what's going on. Let's get you to the right people and then we'll go from there. So I'm kind of lucky I can sort of push that on the poor oncologist who has to have their fair share of conversations where it's like, okay, it's actually not easy. But some of them are, honest to goodness, some of the patients will be like, wow, like that lady with the hands, they treated her. I mean, she was fine. She was totally fine. They caught this lymphoma pretty early, and some of the lymphomas are very, very treatable, which is great.
Jennifer: When you say treatable, is that like a chemo thing or a radiation type deal? I'm sure people are wondering.
Dr. Lio: It's out of my bailiwick. I don't know all their stuff, but yes, typically there's a chemo regimen, sometimes there is radiation, things like that, and they have their different protocols. So there are some really, really cool breakthroughs, especially in the kids. Pediatric cancer is incredibly, incredibly optimistic now. It used to be like such a sad kind of thing, we'd be like, oh my gosh, but now, there are incredible breakthroughs in pediatric leukemias and lymphomas and all these different cancers. So many patients really have a much better chance than they did even five or 10 years ago. So there's new innovation. Obviously, it's still scary and obviously, some patients don't make it but there are some new exciting things. So I think that's helpful. And melanoma is another thing, of course, we as dermatologists deal with a bunch. And I've had many patients with melanoma and a lot of the melanomas I find, I always tell the story, the majority in my experience have been incidental.
Dr. Lio: We do all the skin-screening and stuff. I have all these patients are getting checked. Most of them, I find small potatoes. Lots of basal cell and squamous cell cancer, which we can usually treat very, very easily. They're very calm. Patients freak out initially, especially for their first ones, like, oh my gosh, I have cancer. It's like, nope, I'm like, trust me, the person you were sitting next to in the waiting room probably had 25 of these in the last year. Every time they come in, we take something off. So those are easy.
Dr. Lio: But melanoma is much more serious, and the ones that I've caught, I had a young guy, he was a bodybuilder guy, this is a number of years ago, real buff dude. And he said, I think I have a cyst on my back, it's been bugging me. He had seen a primary doctor, his primary doctor thought it was a cyst too, not unreasonable, it was just sort of a lump. But I said, you know, there's no punctum, a cyst should kind of have that large pore on top. And I kind of mashed on it, I'm like, it doesn't feel like a cyst to my fingers. And I remembered the teaching of one of my favorite mentors, Paul Levins, who's actually now in California, he's at UCLA, he's an incredible dermatologist. And he said, “Peter, we're not allowed to tell a patient we don't know and that it's just benign.” He's like, “If you're not a specialist, you can just say, oh, I don't know what it is, but it's fine.” He's like, “We're not allowed to do that. We actually have to put a name on it.”
Dr. Lio: That kind of haunted me in that moment. I said, I don't think it's anything bad, but I don't know what it is, so I'm freaked out. So I took a biopsy, and sure enough, it was an invasive melanoma. It was an amelanotic melanoma, which is a thing that makes dermatologist lose sleep, no pigment. So it just looked like a lump. And it was pretty thick and pretty deep. And actually, we caught it, we had it removed, he saw a surgical oncologist, he ended up getting some chemo. But he actually did okay, he made it, he survived.
Dr. Lio: I had seen him probably four or five years out. At that point, your chance of death is really, really low. I mean, he was kind of in remission and did it. But that's the kind of situation where a lot of my worst melanomas have been found, these kind of incidental things where people would say, you think it's anything, I'm not worried about it. And I'm like, oh, actually, I'm worried about it.
Jennifer: Well, you bring up a good point about this weird lump cyst thing. Would that possibly look like a lipoma, which could you describe what that is or define what a lipoma is?
Dr. Lio: Sure. Lipomas are really, really common. They're basically little fatty lumps. They're just a little bit of extra fat tissue, it's usually just under the skin. They kind of feel like a little squishy lump or bump. Some people have tons of them, I have some families who make dozens and dozens of them. Some people just have one or two. And generally speaking, they should feel soft and kind of smushy and kind of fatty. They feel like fat, like chicken fat. And if they're not changing or growing and they've been there for a while, I'm usually cool with it. I wouldn't worry. But if somebody says, you know it's growing or it's painful, there's one called an angiolipoma, it's not dangerous but it hurts sometimes, like it kind of hurts, we'll remove them. If we're not sure, we'll say, let's just take it out. If it's freaking you out, I want to just be sure and take it out.
Dr. Lio: And again, like 99.9% are going to be boring, nothing. It's just that once in a while, his didn't feel right, I said, I don't take out every lipoma I see, I see a lot of them. Then I'll say this feels fine to me and we'll keep an eye, but that guy's didn't feel right. So that's how we can sometimes, we kind of make that decision based on the clinical impression.
Jennifer: This is such an interesting conversation, and this underscores the reason why, I have a lot of listeners who will email me and say I don't know what I have. I have this rash, I've had it for a long time, but they've been trying to address it naturally. And I always believe that you should have a team, it's important to have a partnership because I don't, you picked up on something that, because you're trained, as you said, it's crucial to have someone who has training to look at things from that higher level perspective because it is always possible that it could be more serious than just eczema or psoriasis or chronic hives. Have you seen too with chronic, any cases of chronic hives where there have been, that's actually a sign of some sort of lymphoma or cancer issue?
Dr. Lio: Yes. I think in my experience, less commonly is hive something dangerous like that, but it can be other things. We definitely know that people with chronic hives can be what we call pre-bullous bullous pemphigoid. And bullous pemphigoid is a blistering condition, it's an autoimmune blistering condition. Usually it happens in much older people like over 65 that we'll see it in. But sometimes for years they just have kind of bad, I mean, they really look like hives. In fact, even the biopsy looks like hive. So it's not just the clinical impression, even under the microscope, they're really kind of are hives. But they're the beginning of bullous pemphigoid and we've had a few patients where suddenly, we've been trying to treat it, trying to treat it, it won't get better. Gosh, why are these hives so stubborn?
Dr. Lio: And then one day the patient came in and she was an elderly lady. She was like 85 but spunky, full of energy. And she said, “I'd shake your hand, but look,” and she showed me her hand, they were just giant blisters. And I said, “Ah, now we know what you got, you have bullous pemphigoid.” It'd been going almost a year, we had been trying all this stuff and I couldn't get [inaudible 00:19:42]. So it was pre-bullous bullous pemphigoid, a more serious condition, but pretty treatable, we can treat it. But untreated, it can be kind yucky. You get blisters, they can get infected and people can get really sick from it.
Jennifer: Well, I just want to thank you so much for this because it's an important reminder. As I said, you have to have a team and this is where having a dermatologist is important because you need someone to look at things from that higher level. And as I always say, think about symptoms that may be outside of the skin, because that's what you shared is that you could have these symptoms that are like, hey, I'm waking up in the middle of the night, I have night sweats. I have all of these issues and then this sudden onset of eczema, it's just weird and we can't get rid of it. And that really could be a warning sign that something else is going on, where a diet isn't going to fix that. And you do really need specialists to support you through that.
Jennifer: I too do not want anyone to walk away from this conversation scared and thinking that they have cancer, but I also want to remind people that it is important to have your rashes looked at by a dermatologist and to get an annual, what do you call it, a sunspot check or what is that called?
Dr. Lio: A skin check or skin screening. Yeah, that's a great thing to do.
Jennifer: For melanomas and things like that too, correct?
Dr. Lio: Absolutely. If your primary doctor does it, that's great. And usually, they're kind of tuned in. And if there's a spot they're worried about, they can send it in. But many, many, many people come in to do it annually, and we try to accommodate as best we can. Sometimes I get a little overwhelmed, we get so many skin checks, we're trying to get the patients with rashes, but it's such a good thing. And of course, most importantly, if there's a spot you're worried about or there's something that doesn't make sense, get that checked. That's definitely what we're there for.
Dr. Lio: And even if you don't like what your dermatologist says, if they say, oh, I want to put steroids on and you say, I don't want to use steroids, at least we say, okay, we kind of know at least we're not worried that it's something more nefarious, something more scary. So then we can go our other directions. But I like to have that at least as an anchor point that we say, we feel good, we have a diagnosis, we're confirmed, we're not worried about other things.
Jennifer: Well, thank you so much for sharing all of this and just providing people with a different perspective. As always, you are one of the most empathetic physicians and dermatologists I know and I love having you on the show, and I just appreciate your approach to how you have helped so many people and you continue to give and be so generous with your time and your wisdom. So, thank you so much, Dr. Lio, I really appreciate it.
Dr. Lio: Well, thanks for having me. I love talking with you and it's so fun. And even if we help just one or two people, that to me makes it worth it.
