Predictors of Tumor Response to Cetuximab and Panitumumab in 116 Patients and a Review of Approaches to Managing Skin Toxicity.

INTRODUCTION AND OBJECTIVES: Cetuximab and panitumumab are monoclonal antibodies that target the epidermal growth factor receptor (EGFR) in the treatment of metastatic colorectal cancer. Most patients develop a papulopustular rash, which may predict tumor response. We studied whether the other adverse cutaneous effects associated with these monoclonal antibodies are also clinical predictors of response. We also reviewed publications describing approaches to treating the papulopustular rash since no evidence-based guidelines have yet been published. MATERIAL AND METHODS: We performed a retrospective study of 116 patients with metastatic colorectal cancer receiving anti-EGRF therapy with cetuximab or panitumumab at Hospital Universitario Donostia. RESULTS: In total, 81.9% of the patients developed a papulopustular rash. Patients who received the most cycles of treatment with the EGFR inhibitor were at the highest risk of developing the rash, and these patients also had the most severe rash reactions (P=.03). All of the patients who exhibited a complete tumor response had the rash, and the incidence of rash was lower in patients with poor tumor response (P=.03). We also observed an association between tumor response and xerosis (53.4% of the patients who developed xerosis also exhibited tumor response, P=.002). The papulopustular rash was managed according to an algorithm developed by our department. CONCLUSIONS: Severe papulopustular rash and xerosis may be clinical predictors of good response to anti-EGFR therapy. Patients who develop a papulopustular rash should be treated promptly because suboptimal treatment of this and other adverse effects can lead to delays in taking the prescribed anti-EGFR dose or to interruption of therapy.

[Pulmonary Kaposi's sarcoma in a heterosexual parenteral drug addict patient with the acquired immunodeficiency syndrome]. / Sarcoma de Kaposi pulmonar en un paciente heterosexual adicto a drogas por vía parenteral con síndrome de inmunodeficiencia adquirida.

A case of Kaposi syndrome is described in a 28-year-old heterosexual male with acquired immunodeficiency syndrome. The disease began clinically with pulmonary disease, without mucocutaneous lesions. This form of presentation is extremely infrequent and has not been described in non-homosexual subjects. Clinical manifestations were fever, cough and dyspnea. Thoracic radiography observed a perihilar interstitial pattern which evolved to a bilateral nodular pattern with perihilar adenopathy. There was endobronchial disease, however pulmonary biopsy was required for diagnosis. Complete tumoral remission was achieved with adriamycin, bleomycin and vincristine.

[Lyell syndrome associated with lamotrigine]. / Síndrome de Lyell asociado a lamotrigina.

INTRODUCTION: Lamotrigine (LTG) is a new antiepileptic of habitual use in monotherapy as much in partial epileptic as in generalised, which presents among other adverse effects: slight rashes and less frequently severe rashes such as Stevens-Johnson syndrome and Lyell syndrome or toxic epidermal necrolysis, above all in combination with valproate (VPA). CLINICAL CASE: A 44-yr-old woman in toxico-alcoholic epileptic treatment with VPA, showed a neutropenia possibly of secondary type which it was intended to change to LTG, following an ascending dose of LTG joined to a descending dose of VPA. In the sixth treatment week, the patient developed an erythematous rash which after a week of solar exposure, presented temperature, general discomfort, and in the head, on the front and back part of the thoracic and upper and lower limbs, erythematous lesions with scabbed areas, loosening epidermis areas with a positive Nikolsky sign and severe mucous membrane involvement, being diagnostic of Lyell syndrome. The lesions got slowly better with serum therapy, antibiotherapy, parenteral corticoids and topical treatments. CONCLUSIONS: There is a probability of severe rash associated with lamotrigine which has to be taken into account, and we advise patients to suppress the medication when they present a minimum rash.

[Segmental neurofibromatosis]. / Neurofibromatosis segmentaria.

Two additional cases of segmental neurofibromatosis (type V) are reported. This form of neurofibromatosis is manifested by neurofibromas or cafe-au-lait spots in a dermatomal or segmental distribution. Previously reported cases are reviewed. Their clinical manifestations, prognosis and the relationship between the classical neurofibromatosis and segmentary neurofibromatosis are discussed.

[Linear sebaceous nevus syndrome]. / Síndrome del nevus sebáceo lineal.

We report a patient that fulfills the clinical features of the linear nevus sebaceous syndrome. This syndrome was defined by the triad: Linear nevus sebaceous, seizures and mental retardation. Further descriptions suggested an association with hamartomas of mesenchymal structures and increased risk of neoplasm transformation. Previously reported cases are reviewed. The complexity of classification of this neurocutaneous syndrome is discussed.

[Update of the topical treatment of psoriasis]. / Revisión actualizada del tratamiento tópico de la psoriasis.

Topical therapy continues to be one of the pillars of psoriasis management. Topical corticosteroids and vitamin D analogs are the drugs of choice during the induction phase, and vitamin D analogs continue to be drugs of choice for maintenance therapy. Tazarotene and dithranol are suitable options in patients with certain, specific characteristics. The calcineurin inhibitors can be considered to be second-line treatment for psoriasis of the face and flexures. The efficacy and safety of the fixed-dose combination of betamethasone and calcipotriol in the induction phase is greater than that of either drug alone. The combination of corticosteroids with salicylic acid achieves better results than corticosteroids in monotherapy. None of the drugs evaluated stands out over the others in all clinical situations, and their use must therefore be individualized in each patient and adjusted according to the course of the disease.

Cutaneous reactions secondary to heparin injections.

Ten to 20 days after starting prophylactic doses of heparin in six patients, large, indurated, erythematous plaques appeared at the sites of the subcutaneous injections. Pruritus, local tenderness, and burning sensation or pain were present. No skin necrosis developed. Heparin was discontinued and topical corticosteroids were applied to the involved areas. Five to 9 days later the lesions had resolved completely. The reaction seen in the six patients is similar to the early erythematous phase of the so-called heparin necrosis. There is a spectrum of cutaneous changes ranging from mild erythematous pruritic areas to large symptomatic plaques and to heparin necrosis, following subcutaneous injections of heparin.

Eosinophilic histiocytosis. A subset of lymphomatoid papulosis.

A 43-year-old male with a 23-year history of small-plaque-type parapsoriasis developed a chronic recurrent self-healing papulonodular and tumoral cutaneous eruption. The microscopic findings were consistent with eosinophilic histiocytosis. Immunohistochemical and ultrastructural studies revealed a population of T lymphocytes, eosinophils and monocyte-macrophage cells in the dermal infiltrate. These findings confirm the similarities between eosinophilic histiocytosis and lymphomatoid papulosis suggesting that the former may be a clinicopathologic variant of the latter.

Trichothiodystrophy associated with urologic malformation and primary hypercalciuria.

Trichothiodystrophy (TTD) is a hair abnormality that may be associated with a large number of alterations affecting the skin phenotype and skin appendages, nervous system, eyes, bones, and immune, gonadal, and endocrine systems. We report the first case of TTD associated with a urologic malformation and primary hypercalciuria. Our patient had congenital ichthyosis, physical and mental retardation, and a dysmorphic facies associated with a complex urologic malformation and primary hypercalciuria. Characteristic features of his hair under microscopic examination (trichoschisis, alternating light and dark bands under polarizing microscopy, and a severely defective cuticle) and low sulfur content by radiographic microanalysis confirmed the diagnosis. We discuss the meaning of this new association in the spectrum of abnormalities related to TTD.

Perforating lichen striatus.

A case of lichen striatus with transepidermal elimination of clusters of necrotic keratinocytes is reported. On the basis of the morphologic findings, we suggest that transepidermal elimination may be a mechanism of healing in some cutaneous lichenoid eruptions.