Erosive Pustular Dermatosis of the Scalp-Like Eruption due to Gefitinib: Case Report and Review of the Literature of Alopecia Associated with EGFR Inhibitors

Abstract

A 69-year-old Japanese woman with multiple brain metastases secondary to non-small-cell lung cancer was treated with radiosurgery, and subsequently started oral gefitinib. Three years later, she presented with erythematous erosive alopecia with pustules on the scalp. A biopsy specimen showed a dense perifollicular infiltration composed of lymphocytes, neutrophils and abundant plasma cells. Methicillin-resistant Staphylococcus aureus was cultured from the lesions; however, treatment with antibiotics was not effective. We diagnosed an eruption resembling erosive pustular dermatosis of the scalp. Although oral steroids did not improve the lesions, the pustules and erythema of the scalp rapidly improved within a few weeks after discontinuation of gefitinib. There have been only 11 case reports of alopecia associated with epidermal growth factor receptor (EGFR) inhibitors including our case. It is noteworthy that all cases were female, and most cases involved the parietal scalp. Moreover, the reduction or discontinuation of the EGFR inhibitors was needed in all cases with erythematous alopecia, which remained as scarring alopecia.

Trichoscopic Findings of Erosive Pustular Dermatosis of the Scalp Associated with Gefitinib

“…However, the mechanism of scalp inflammation associated with EGFR inhibitors is not fully understood. Most cases of alopecia associated with EGFR inhibitors show EPDS as our patient [5], while a few show tufted hair folliculitis (THF) [6, 7]. Because these side effects have potential to progress to scarring alopecia, dermatologists should make an early diagnosis.…”

“…Because these side effects have potential to progress to scarring alopecia, dermatologists should make an early diagnosis. The available treatment for EPDS is topical high-potency steroids [8], though it has poor effect on EPDS associated with EGFR inhibitors [5]. The best treatment for EPDS eruption associated with EGFR is dose reduction or discontinuation of EGFR inhibitors.…”

Erosive Pustular Dermatosis: A Manifestation of Immunosenescence A Report of 8 Cases

“…When eventual healing does occur, there is typically residual scarring alopecia in affected areas of the scalp, or scarring with post-inflammatory hyperpigmentation on the legs [1,5]. Triggering factors include various forms of damage to cutaneous integrity including physical and topical therapy, surgery, malignancy, and trauma [5,6,7,8,9,10,11]. Acute pustulosis of the scalp is a newer variant of the disease that has been recently described [12].…”

Extreme phenotype of epidermal growth factor receptor inhibitor-induced destructive folliculitis

“…[12] Erlotinib and gefitinib have been associated with inflammatory nonscarring alopecia,[1314] and severe forms of scalp involvement include folliculitis decalvans (FD),[15] scarring alopecia,[16] or erosive pustular dermatosis of the scalp. [17] Here, we report on the manifestations and management of a severe form of EGFRI-associated scarring alopecia.…”