Flagellate Dermatitis as a Bleomycin-Specific Adverse Effect of Cytostatic Therapy

Abstract

In oncology, bleomycin is a frequently used drug for the treatment of several malignancies. In particular, it is part of chemotherapy protocols in testicular cancer. We report on two patients with testicular cancer who received bleomycin-including chemotherapy and developed flagellate dermatitis. This is a typical adverse effect of bleomycin therapy; however, its pathophysiology has not yet been clarified. We discuss possible pathophysiologic mechanisms for this reaction. In general, it has been postulated that histopathologic findings in flagellate dermatitis share similarities with those observed in fixed drug eruptions. In fact, published cases in the literature have shown a broad variety of histologic changes and the histopathologic investigation of our two patients was not indicative of fixed drug eruption-like changes. Histology of one patient showed a superficial and deep, perivascular and periadnexal infiltrate of lymphocytes and eosinophils with a prominent perisudoral distribution, whereas the other patient was remarkable only for the presence of a rather sparse, superficial, perivascular lymphocytic infiltrate with occasional eosinophils and a few melanophages. Epidermal changes, in particular necrotic keratinocytes, were not present in either patient. We provide an overview of all reported histologic changes in bleomycin-induced flagellate dermatitis, including our experience with two patients. Based on these data, we present a summary of the clinical and histologic features.

Flagellate Hyperpigmentation Following Treatment with Low-Dose Bleomycine: Report of two cases

“…The linear or streaked pigmentation usually develops after a cumulative dose between 100-300 U of bleomycin (6,17), whereas considering our cases the cumulative doses were 38 U and 30 U. There are only 17 adult cases of FH following treatment with low-dose bleomycin (Table 1) (2,4,6,8,9,14,15,(17)(18)(19)(20)(21)(22)(25)(26)(27). It is observed that the majority of patients developing FH within 7 days of administration of bleomycin were young adults, even the dose of bleomycin was between 5-30 U.…”

Bleomycin Induced Flagellate Erythema: a Rare and Unique Drug Rash

“…Flagellate dermatitis has also been reported in patients receiving other chemotherapeutic agents such as peplomycin, a bleomycin derivative, and docetaxel (12,13). Flagellate dermatitis can also occur in association with consumption of shiitake mushroom, dermatomyositis, adult-onset Still's disease and infection with human immunodeficiency virus (4,6). In most cases, the rash resolves spontaneously.…”

“…Addressing the symptom of itch is the main treatment measure (14). Treatment with antihistamines and topical and oral corticosteroids may be required (4). Severe rash requires discontinuation of bleomycin (4).…”

Bleomycin-induced-flagellate dermatitis: Figure 1:

“…1,2 Minor trauma to the skin, such as pressure over bony prominences and scratching, is thought to increase blood flow and cause local accumulation of bleomycin. 3 Flagellate dermatitis and subsequent hyperpigmentation in the skin is fairly common among patients receiving bleo mycin, with reported incidence between 8% and 22%. 3 Flagellate dermatitis is not typically associated with the other medications our patient was receiving.…”

“…3 Flagellate dermatitis and subsequent hyperpigmentation in the skin is fairly common among patients receiving bleo mycin, with reported incidence between 8% and 22%. 3 Flagellate dermatitis is not typically associated with the other medications our patient was receiving.…”