Cutaneous hyperpigmentation following bleomycin sclerotherapy for vascular malformations

Abstract

Systemic bleomycin therapy is associated with pulmonary fibrosis and cutaneous side effects. While it is believed that there is little to no systemic distribution of bleomycin when utilized to treat vascular malformations (VMs), we present a case series in which cutaneous, adhesive‐related hyperpigmentation suggests that there is systemic egress of bleomycin following direct puncture sclerotherapy (DPS). This risk of hyperpigmentation after intralesional bleomycin should be discussed with patients, and steps to minimize the chances of it occurring should be implemented.

Utilizing Cohesive Bandage to Prevent Adverse Effects of Bleomycin Sclerotherapy: A Case Report

“…7 Systemic distribution of bleomycin with sclerotherapy remains uncertain; however, it is likely lower than IV doses. 7 Microtrauma due to scratching, pressure, or adhesive removal on ECG leads, securing IV lines, or pulse oximeters can cause dermal accumulation of bleomycin from the systemic bleomycin leaking out of the blood vessels, leading to cosmetic sequelae such as flagellate dermatitis, with a characteristic whip-like appearance, and hyperpigmentation, which has been described as a Koebner-like phenomenon. 3,4 Care using adhesives is also imperative in patients to prevent epidermolysis bullosa, a hereditary skin disorder characterized by fragility and blister formation, readily triggered by minor trauma.…”

“…3,4 Direct injection limits the systemic absorption of bleomycin and its consequent systemic toxicity and side effects. 7 Systemic distribution of bleomycin with sclerotherapy remains uncertain; however, it is likely lower than IV doses. 7 Microtrauma due to scratching, pressure, or adhesive removal on ECG leads, securing IV lines, or pulse oximeters can cause dermal accumulation of bleomycin from the systemic bleomycin leaking out of the blood vessels, leading to cosmetic sequelae such as flagellate dermatitis, with a characteristic whip-like appearance, and hyperpigmentation, which has been described as a Koebner-like phenomenon.…”

“…Although recommendations exist for avoiding hyperpigmentation following direct puncture sclerotherapy for VMs, 7 their discussion of adhesives mainly focused on using smaller adhesive items and delaying their removal. We show that these items can be secured with a cohesive bandage rather than direct skin adhesives to allow the use of standard electrodes and avoid delaying removal.…”

“…We show that these items can be secured with a cohesive bandage rather than direct skin adhesives to allow the use of standard electrodes and avoid delaying removal. 7 Our practice in these cases includes all adhesive removal from the ECG leads and the pulse oximeter or using a plastic pulse oximeter. The LMA, IV lines, ECG leads, and oximeter can be secured with cohesive bandages to avoid the microtrauma of tape removal.…”

“…This report shows a method of avoiding skin damage using cohesive bandages in a patient undergoing bleomycin sclerotherapy that complements other recommendations. 7 Further investigation could evaluate cohesive bandages and similar products in higher-dose bleomycin regimens, such as chemotherapy for lymphomas, germ cell tumors, or pleurodesis of malignant pleural effusions. 13 We have only used 3M Coban wrap, but 3M Cavilon solution could be investigated concerning bleomycin-induced flagellate dermatitis as its primary purpose is, according to the manufacturer, to prevent medical adhesive–related skin injury.…”