Illustration depicting Papuloerythroderma of Ofuji (PEO) rash, highlighting the characteristic sparing of skin folds.

Decoding Ofuji's Papuloerythroderma: When Skin Reveals a Deeper Story

Reese Marlowe in Health & Wellness July 2025 • 4 min read.

"Unveiling the link between a rare skin condition and myelodysplastic syndrome, and what it means for early diagnosis and treatment."

Papuloerythroderma of Ofuji (PEO) is a rare skin condition characterized by red-brown papules that merge into widespread redness, notably sparing skin folds – a telltale sign known as the 'deck-chair sign.' While PEO has been linked to various triggers, including medications, infections, and even malignancy, its association with underlying conditions makes early recognition critical.

Malignancy, in particular, has been observed in a significant proportion of PEO patients, underscoring the importance of considering this possibility when diagnosing the condition. Recognizing PEO as a potential paraneoplastic phenomenon – where the skin condition signals an underlying cancer – can lead to earlier detection and potentially better outcomes.

This article explores a case of PEO associated with myelodysplastic syndrome, a type of blood cancer, highlighting the diagnostic challenges and the importance of recognizing this rare dermatosis as a potential indicator of more serious health issues. Understanding the subtle clues our skin provides can be life-saving.

The Case: When a Rash Signaled a Blood Disorder

Illustration depicting Papuloerythroderma of Ofuji (PEO) rash, highlighting the characteristic sparing of skin folds.

Consider the case of a 77-year-old Chinese man with a history of hypertension, who presented with an 11-month history of an intensely itchy rash. Initially treated for asteatotic eczema with topical steroids, his condition only worsened. This case highlights how PEO can mimic other skin conditions, delaying accurate diagnosis.

Physical examination revealed the characteristic red-brown papules and confluent scaly plaques, with striking sparing of the abdominal folds (the 'deck-chair sign'). A skin biopsy, while not definitive on its own, showed features suggestive of PEO. However, it was a blood test that ultimately revealed the underlying issue: new-onset leukopenia (low white blood cell count), atypical mononuclear cells, and immature blasts.

Leukopenia and abnormal cells: Blood tests showed low white blood cell counts and unusual cells.
Bone marrow confirmation: A bone marrow evaluation confirmed myelodysplastic syndrome.
Cytogenetic abnormality: The patient had a monosomy-7 cytogenetic abnormality, indicative of a poor prognosis.

The patient was diagnosed with PEO associated with myelodysplastic syndrome, a type of blood cancer affecting the bone marrow. Despite treatment, his condition remained challenging, and he ultimately passed away from pneumonia five months later. This case underscores the aggressive nature of some PEO-associated malignancies and the importance of prompt diagnosis.

PEO: More Than Just Skin Deep

While the exact cause of PEO remains elusive, research suggests a link to Th22- and Th2-mediated inflammation. These immune responses can promote both skin cell proliferation and, potentially, tumor growth. This connection underscores the complexity of PEO and the need for a comprehensive diagnostic approach.

Diagnosis of PEO can be challenging, with a median duration of 7 months from onset to diagnosis. Diagnostic criteria include the characteristic skin findings (flat-topped papules, erythroderma, sparing of skin folds), itchiness, and exclusion of other skin diseases. Recognizing these key features is the first step toward identifying potential underlying conditions.

PEO serves as a reminder that skin conditions can be a window into overall health. Recognizing PEO and its potential association with malignancy can lead to earlier diagnosis and intervention, potentially improving outcomes for those affected. If you notice unexplained skin changes, especially those resembling PEO, seeking prompt medical attention is crucial.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1111/ajd.12703, Alternate LINK

Title: Papuloerythroderma Of Ofuji Presenting As A Paraneoplastic Phenomenon In Myelodysplastic Syndrome

Subject: Dermatology

Journal: Australasian Journal of Dermatology

Publisher: Wiley

Authors: Dingyuan Wang, Michelle Mei Fung Chan, Haur Yueh Lee

Published: 2017-08-03

Everything You Need To Know

What is the 'deck-chair sign' in Papuloerythroderma of Ofuji, and why is it important?

Papuloerythroderma of Ofuji presents with red-brown papules that merge into widespread redness, but a key characteristic is the sparing of skin folds, creating what's known as the 'deck-chair sign'. This means that while most of the skin might be affected, the folds, such as those in the abdomen or neck, are noticeably less inflamed. The appearance of 'deck-chair sign' is extremely important as it distinguishes it from other skin conditions, like eczema, that have a more generalized pattern.

What is myelodysplastic syndrome, and what does its association with Papuloerythroderma of Ofuji imply?

Myelodysplastic syndrome is a type of blood cancer that affects the bone marrow's ability to produce healthy blood cells. In the context of Papuloerythroderma of Ofuji, its presence suggests that the skin condition may be a paraneoplastic phenomenon. This means the skin changes are a consequence of the underlying cancer. Early detection of myelodysplastic syndrome is crucial, as it can progress to more aggressive forms of leukemia, highlighting the importance of recognizing PEO as a potential early warning sign.

What causes Papuloerythroderma of Ofuji, and how is inflammation involved?

Currently, the exact cause of Papuloerythroderma of Ofuji is not fully understood, but research indicates a connection to Th22- and Th2-mediated inflammation. These immune responses can stimulate skin cell proliferation. The relationship between these inflammatory pathways and Papuloerythroderma of Ofuji is an area of ongoing investigation, but understanding these mechanisms could lead to more targeted and effective treatments.

Can you elaborate on the specifics of the patient case and its implications for Papuloerythroderma of Ofuji diagnosis and treatment?

The case described involved a 77-year-old man initially treated for asteatotic eczema who later was found to have Papuloerythroderma of Ofuji associated with myelodysplastic syndrome. His blood tests revealed leukopenia, atypical mononuclear cells and immature blasts, with a bone marrow evaluation confirming myelodysplastic syndrome. The man also had monosomy-7 cytogenetic abnormality, indicating a poor prognosis. Despite treatment, he succumbed to pneumonia five months later. The case highlights the challenges in diagnosis, the potential for aggressive underlying conditions, and the critical need for vigilance when encountering Papuloerythroderma of Ofuji.

What steps should be taken if Papuloerythroderma of Ofuji is suspected?

If Papuloerythroderma of Ofuji is suspected, a comprehensive diagnostic approach is essential. This typically includes a thorough physical examination to identify the characteristic skin findings, such as the 'deck-chair sign.' A skin biopsy can provide supportive evidence, but blood tests are crucial to evaluate for underlying systemic conditions like myelodysplastic syndrome. Bone marrow evaluation and cytogenetic analysis may also be necessary to confirm the diagnosis and assess the prognosis.