Bleomycin-induced flagellate erythema: A case report and review of the literature

Abstract

Bleomycin has been used most commonly in the treatment of Hodgkin’s lymphoma, certain germ cell tumors (GCT) and for the sclerosis of recurrent pleural effusions. Bleomycin toxicity predominantly affects the skin and lungs. Skin toxicity includes Raynaud’s phenomenon, hyperkeratosis, nail-bed changes and palmoplantar desquamation. Flagellate erythema is an unusual rash occurring specifically during bleomycin use. In the present study, we report a case of bleomycin-induced flagellate erythema in a patient with GCT. A 42-year-old male was diagnosed with stage IIIB testicular cancer and treated with bleomycin, etoposide and cisplatin chemotherapy. After 10 days from the initiation of treatment, the patient subsequently developed a generalized pruritus and erythematous linear rash that was most prominent on the trunk, and upper and lower extremities. The patient was commenced on a short course of low-dose oral prednisolone, 20 mg daily, and antihistamine. Consequently, bleomycin was withheld from the patient’s treatment regimen. The present study describes the case, along with a review of the associated literature.

Chemotherapy-Related Reticulate Hyperpigmentation: A Case Series and Review of the Literature

“…We should stress that none of our patients presenting reticulate hyperpigmentation were treated with bleomycin. Moreover, whip-like striated lesions observed with bleomycin usually develop in a well-demarcated linear configuration and are most often papular and larger [17,18,20]. Flagellate dermatitis also mainly involves the back and pressure areas, but the lesions are generally more self-limiting and preceding pruritic erythematous linear streaks, sometimes severe, are much more frequently noted in comparison with reticulate hyperpigmentation [15,17,18,19].…”

“…However, histopathological changes are not uniform and a broad spectrum of histological features has been reported, including perivascular or perisudoral lymphoeosinophilic cell infiltration, hyperkeratosis with focal parakeratosis and spongiosis [15,16,17]. Pathophysiological mechanisms leading to flagellate hyperpigmentation are still unknown, but a local toxic effect after drug leakage within the skin or a reduced epidermal turnover with prolonged contact between melanocytes and keratinocytes have been postulated [15,17,20]. Finally, it has been hypothesized that bleomycin may persist longer in the skin due to a lower level of bleomycin hydrolase [15,16].…”

“…More specific clinical presentations have been less frequently identified such as serpentine supravenous hyperpigmentation (mainly with 5-fluorouracil) [11,12,13,14] or bleomycin-induced flagellate hyperpigmentation [15,16,17,18,19,20,21]. …”

Bleomycin‐induced flagellate erythema after venous malformation sclerosis—Case report and brief review

“…Usually erythema has a self‐limited course of several weeks to months, although permanent hyperpigmentation in affected areas may develop as the rash resolves . This rash may appear regardless of the route of administration of bleomycin: intravenous, intramuscular, topical, or even intrapleural …”

Foamed bleomycin sclerosis of airway venous malformations: The role of interspecialty collaboration

“…Bleomycin toxicity involves the skin and lungs. Cutaneous complications include hyperpigmentation, Raynaud's phenomenon, and flagellate erythema . These typically occur at cumulative doses greater than 100 units but have also been reported at lower doses .…”