Bleomycin induced flagellate erythema: Revisiting a unique complication

Abstract

Bleomycin induced flagellate dermatitis is a rare and unique adverse effect. With the declining use of bleomycin, this complication is becoming increasingly infrequent in common clinical practice. We herein describe a case of a 22-year-old Indian male with Hodgkin's lymphoma, Ann Arbor stage IIBEX developing flagellate dermatitis following 1(st) cycle of chemotherapy with ABVD regimen. The diagnostic dilemma in the illustrative case underscores the importance of awareness and prompt identification and treatment of this dermatological toxicity in limiting morbidity in patients undergoing bleomycin based combination chemotherapy. In patients having severe rash, bleomycin should be expeditiously discontinued. Omission of bleomycin does not compromise the treatment outcome in the majority of patients with Hodgkin's lymphoma.

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.…”

“…It is widely used in the treatment of malignancies such as lymphomas, germ cell tumors, and squamous cell carcinoma (4). At low doses, it inhibits mitosis; however at higher concentrations, it exhibits strong cytostatic activity by blocking the DNA uptake of thymidine in the S-phase of the cell cycle (4,5). Fifty percent of bleomycin is inactivated by an aminohydrolase.…”

“…Fifty percent of bleomycin is inactivated by an aminohydrolase. Bleomycin-induced toxicity predominantly affects the lungs and skin due to the low levels of hydrolase in these tissues (2)(3)(4)(5). Mucocutaneous side effects of bleomycin are common, and include stomatitis, ulcers, erythematous and bullous lesions, sclerosis, nail changes, digital gangrene, Raynaud's phenomenon, and hyperkeratosis (5,6).…”

“…Mucocutaneous side effects of bleomycin are common, and include stomatitis, ulcers, erythematous and bullous lesions, sclerosis, nail changes, digital gangrene, Raynaud's phenomenon, and hyperkeratosis (5,6). FH is one of the most interesting side effects, and it may occur in 8-20% of patients who receive bleomycin treatment (4,6). Diagnosis is based on the characteristic clinical appearance of skin lesions.…”

“…Diagnosis is based on the characteristic clinical appearance of skin lesions. Lesions are usually seen on the upper trunk and limbs and may be associated with pruritus (2,4,6). It can be said that hyperpigmented streaks are generally localized on areas of pressure in linear, or streaked (7).…”