Cremophor-Induced Lupus Erythematosus-Like Reaction with Taxol Administration: A Case Report and Review of the Literature

Abstract

We report the first case of Cremophor EL-induced cutaneous lupus erythematosus-like reaction in a 40-year-old female undergoing treatment for breast cancer. There have been four reported cases of paclitaxel- and four cases of docetaxel-induced cutaneous lupus reactions in the published literature [Dasanu and Alexandrescu: South Med J 2008;101:1161–1162; Adachi and Horikawa: J Dermatol 2007;34:473–476; Lortholary et al: Presse Med 2007;36:1207–1208; Chen et al: J Rheumatol 2004;31:818–820]. Our patient developed findings of a cutaneous lupus-like reaction with administration of paclitaxel which was subsequently discontinued. She was re-challenged with albumin-bound paclitaxel which has no Cremophor EL compound in its formulation. This administration of albumin-bound paclitaxel did not induce further reaction. She did not develop a cutaneous lupus erythematosus-like reaction with three other subsequent administrations of albumin-bound paclitaxel. The diagnosis of lupus-like reaction in our patient was made based on the development of a malar butterfly rash sparing the nasolabial folds, the appearance of this rash in context of recently receiving treatments with paclitaxel, resolution of the rash after discontinuing the paclitaxel, and the presence of autoimmune antibodies in the patient’s serum which resolved with discontinuation of the paclitaxel. This is the first case demonstrating that the cause of the cutaneous lupus erythematosus-like reaction is not likely due to the taxane component of paclitaxel but the chemical composition of Cremophor EL. If the chemotherapeutic agent was causing the reaction then the same reaction should be seen by albumin-bound paclitaxel. We propose that previously reported lupus reactions may actually be due to Cremophor EL, which consists of polyoxyethylated castor oil, and not the chemotherapeutic agent itself.

Subacute Cutaneous Lupus Erythematosus Induced by Chemotherapy

“…While the common presumption is that the chemotherapeutic drug itself is the culprit, a recent study 17 showed that a patient who developed a cutaneous lupus-like reaction with the administration of paclitaxel showed no such reaction with 4 subsequent administrations of albumin-bound paclitaxel, which does not contain a polyoxyethylated castor oil emollient (called Cremophor EL) in its formulation. The authors propose that other reports of paclitaxel-induced SCLE may in fact be due to this polyoxyethylated castor oil emollient and not the chemotherapeutic agent.…”

Drug-induced subacute cutaneous lupus erythematosus associated with docetaxel chemotherapy: a case report

“…In the current literature, there have been eight reported cases of SCLE associated with docetaxel, and five reported cases of SCLE associated with paclitaxel chemotherapy [ 1 – 13 ]. Many of the patients in these cases had a background of preceding autoimmune disease with positive anti-SSA/Ro antibodies [ 1 – 5 , 8 , 10 , 11 ]. It has been suggested that the presence of serum anti-SSA/Ro antibodies may be involved in a mechanism that predisposes patients to a higher risk of developing drug-induced SCLE [ 4 , 14 ].…”

Drug-Induced Subacute Cutaneous Lupus Erythematosus Associated with Nab-Paclitaxel Therapy

“…Other chemotherapies, including docetaxel and capecitabine, have been associated with druginduced scle in the literature [11][12][13] . Also, scle is not the only presentation of dile caused by chemotherapeutic agents; paclitaxel itself is a described cause of other dile syndromes 14,15 .…”

“…The original formulation of paclitaxel was emulsified using polyethoxylated castor oil, a vehicle known to possess pharmacologic properties leading to adverse effects, including severe hypersensitivity reactions 16,17 . Many of paclitaxel's idiosyncratic adverse effects-including dile reactions-have previously been attributed to polyethoxylated castor oil rather than to the parent chemotherapy molecule [15][16][17] . Nab-paclitaxel is a new-generation solvent-free formulation of paclitaxel that utilizes nab technology to increase the bioavailability of the paclitaxel molecule 18 .…”

“…Pham et al 15 previously described a case of dile with systemic lupus erythematosus-like features occurring during paclitaxel therapy and resolving with paclitaxel withdrawal. The clinical features of their case included malar rash and antinuclear antibody positivity, a dile syndrome distinct from scle.…”