Chronic lymphocytic leukemia (CLL) is one of the most common types of leukemia seen in adults. It primarily affects the blood and organs like the lymph nodes, spleen, and liver. But it can also affect your body’s largest organ — your skin. People living with CLL may describe cutaneous (skin) symptoms as lesions, rashes, or eruptions.

Skin conditions in CLL come in two types — specific and nonspecific. Specific skin lesions are caused by leukemia itself invading the skin, and about 25 percent of people living with CLL will experience them. Skin conditions that fall under this category include leukemia cutis and Richter syndrome.

Nonspecific skin problems don’t involve leukemia cells. These skin changes vary from person to person. Nonspecific skin issues occur in between 30 percent and 50 percent of people living with CLL. Most nonspecific skin symptoms are caused by some type of infection or allergy, but they can also include tumors.

In this article, we’ll discuss the most common skin problems associated with CLL. You’ll learn what they can look like and how CLL affects the immune system. Finally, we’ll share when to talk to your doctor and what skin problems may be most likely to need medical care.

1. Leukemia Cutis and Richter Syndrome

Sometimes, CLL cancer cells can move from the blood into the skin. This is called leukemia cutis. Doctors describe this as infiltration, which means cancer cells enter tissues where they don’t normally belong. Researchers don’t exactly know how this happens, but it may have to do with how blood cancer cells and skin cells interact with one another.

While leukemia cutis is uncommon, it does happen. Recent studies estimate that it’s usually found in fewer than 5 percent of people with CLL. Leukemia cutis can show up as:

• Papules (small, superficial bumps)
• Nodules (larger bumps under the skin)
• Plaques (raised or thick areas)

A skin biopsy — taking a small amount of tissue to be examined under a microscope — is needed to confirm that you have this condition.

It’s important to recognize leukemia cutis because it can be a sign of Richter syndrome. However, leukemia cutis alone doesn’t prove that someone has Richter syndrome. Also known as “Richter transformation,” this syndrome occurs when CLL becomes an aggressive form of lymphoma. It usually shows up as a sudden and dramatic growth of lymph nodes. This type of disease progression affects about 7 percent of people with CLL.

“My oncologist is suspecting Richter transformation since one of the internal lymph nodes that measured 2 centimeters earlier this year is now at 11 centimeters,” shared one MyLeukemiaTeam member.

2. Skin Infections

Most skin lesions in CLL aren’t related to leukemia itself. Instead, they often come from infections. CLL and many cancer treatments can weaken the immune system, making people more likely to develop bacterial, viral, and fungal infections.

For example, shingles (herpes zoster) is more common in people with CLL. One study found that 7 percent to 15 percent of people with CLL treated with chemotherapy and immunotherapy together later developed shingles.

Cold sores and other herpes simplex virus infections may also occur more often with CLL.

Nonspecific skin lesions are typically caused by toxic and allergic factors. Reduced immunity may play a role, but these skin changes can also occur because of the drugs used to treat CLL. One MyLeukemiaTeam member shared, “I have terrible itching and hives. These are all side effects from the CLL medication.”

Watch out for any new rashes or swelling along with flu-like symptoms. Contact your healthcare team if you feel ill while starting CLL treatment.

3. Second Skin Tumors

People with CLL have a higher risk of developing skin cancer, but the exact risk level depends on the type of tumor. These tumors are called “second” skin tumors because they develop after CLL. CLL and its treatment both disrupt the normal immune system, which increases the risk for certain secondary cancers. “Skin cancer is something most of us have to deal with,” noted one MyLeukemiaTeam member.

Skin cancer falls into two main types: melanoma and nonmelanoma. The nonmelanoma types associated with CLL include squamous cell carcinoma (SCC) and basal cell carcinoma (BCC).

Squamous Cell Carcinoma

SCC often appears on sun-exposed areas of skin, like the face, ears, scalp, and limbs. However, it can show up anywhere. In people with darker skin, for instance, SCC tends to affect areas that don’t get sun exposure. It may look like patchy, open sores or wart-like spots that can bleed or crust. As the name suggests, these tumors grow on the skin’s squamous cell layer — the middle and outer part of the skin.

“A few months ago, I had surgery done on my leg for squamous cell carcinoma,” shared one MyLeukemiaTeam member.

Basal Cell Carcinoma

BCC looks similar to SCC, but it develops in basal cells. These cells are also located in the skin’s top layer, but below the squamous cells, in the area where new skin cells are made. Like SCC, BCC also tends to develop in areas exposed to the sun. It may appear as flesh-colored bumps on light skin or as glossy brown or black bumps on dark skin. BCC can occur on the lip, but this is less common — most lip cancers are actually SCC, not BCC.

Melanoma

Melanoma, the most dangerous form of skin cancer, develops on skin cells called melanocytes. Melanocytes can become cancerous from overexposure to ultraviolet (UV) rays. People living with CLL are at an increased risk of melanoma because of having a weakened immune system, often as a result of their CLL treatment. One study found that the risk of melanoma — the deadliest form of skin cancer — may be up to seven times higher in people with CLL.

Melanomas can vary in appearance, but they typically come from moles that are either new or growing. When caught early, melanoma can be cured.

“I was officially diagnosed with CLL in 2008 by my melanoma doctor when he found it doing the blood work for my first melanoma skin cancer,” shared a MyLeukemiaTeam member. “I have had three melanomas, all on my left arm.”

Other Skin Cancers Linked With Chronic Lymphocytic Leukemia

Some less common skin cancers are also associated with CLL. These include Merkel cell carcinoma and Kaposi sarcoma. It’s common to mistake the symptoms of these skin cancers for noncancerous skin issues. Be sure to discuss skin changes with your dermatologist (skin specialist) or hematologist (blood disorder specialist) at follow-up appointments.

4. Other Skin Symptoms

People living with CLL may develop other skin symptoms because of the disease or its treatment. These symptoms include various types of bruising and rashes that look like bug bites.

Bruising

Bruising usually happens after an injury. But if bruises show up without a clear reason, they may be a sign of a medical problem.

In CLL, cancer cells can grow in the bone marrow, making it harder for the body to produce platelets. These are the blood cells that help blood clot. With fewer platelets, people with CLL may experience more bleeding. This explains why people with CLL frequently bruise.

Your provider may use different names for bruising based on size:

• Petechiae — Flat, discolored, dotlike bruises, which are usually harmless but can be a sign of a blood problem
• Purpura — A red, purple, brown, or black rash, depending on your skin tone, with spots that are slightly bigger than petechiae
• Ecchymoses — Bruises that are larger than purpura and petechiae

All of these lesions indicate a low platelet count, which can occur in advanced stages of CLL. However, some people with CLL also develop a condition called immune thrombocytopenia (ITP) — a condition where the body destroys its own platelets. ITP can happen at any time, not only in advanced disease.

Insect Bite-Like Reactions

People with CLL tend to have exaggerated responses to insect bites due to their altered immune system. Additionally, some people with CLL develop “insect bite-like reactions.” These are itchy bumps that look like bug bites, even though no insect is involved. These rashes are recognized in CLL but can vary a lot from person to person. They may also appear in areas you wouldn’t expect to get bitten.

Check With Your Doctor About Skin Issues

Your doctor can help you understand the cause of skin issues with CLL and find the best treatment options. Take note of any new or worsening symptoms of CLL or side effects of medications, and share these with your doctor at your next dermatology or hematology appointment. Many symptoms and side effects will improve with medications and lifestyle changes recommended by your healthcare provider.

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