Late epidermal growth factor receptor inhibitor-related papulopustular rash: a distinct clinical entity.

We report four patients developing a late form of papulopustular rash induced by epidermal growth factor receptor inhibitors. These patients presented an unusual presentation of acneiform rash, characterized by late development (several months after treatment commenced), localization to the limbs with sparing of the face, and association with severe pruritus and Staphylococcus aureus superinfection in all cases. These clinical symptoms may suggest a distinct mechanism from the early acne-like rash frequently observed with these targeted anticancer therapies. Clinicians should be aware of this delayed adverse event, and we suggest the term 'late acneiform toxicity of EGFR inhibitors (LATE) syndrome' to permit better characterization of this clinical picture.

Cutaneous adverse events of epidermal growth factor receptor inhibitors: A retrospective review of 99 cases.

BACKGROUND: Previous reports regarding the cutaneous adverse events of epidermal growth factor receptor inhibitors are mostly limited to small case reports and case series, mainly involving Caucasian patients. AIMS: We describe the trends in the clinical presentation of Asian patients who had cutaneous adverse events induced by epidermal growth factor receptor inhibitors and to explore the relationship between skin adverse events and tumor response. METHODS: From 2006 to 2010, medical records of Thai patients with non-small cell lung cancer receiving epidermal growth factor receptor inhibitors were retrieved and analyzed. RESULTS: In all, 99 patients were reviewed and analyzed. Erlotinib and gefitinib were commenced in 75 (75.8%) and 24 (24.2%) patients, respectively. Cutaneous adverse events occurred in 43 (57.3%) patients receiving erlotinib and in 15 (62.5%) patients receiving gefitinib. The most common adverse event was xerosis (52.5%). Less common adverse events included papulo-pustular eruption (27.3%), erythematous maculopapular rash (11.1%), mucositis (6.7%), paronychia (5.1%), and trichomegaly (2%). Elderly patients had a higher occurrence of xerosis. The presence of cutaneous adverse events was significantly higher in subjects who had a tumor response. LIMITATIONS: The limitations of study include its retrospective nature, and the initial screening of cutaneous adverse events was done by non-dermatologists. CONCLUSIONS: Cutaneous adverse events due to epidermal growth factor receptor inhibitors are not uncommon in the Asian population. We found a positive correlation between the occurrences of cutaneou adverse events and tumor response supporting the view that they are surrogate markers for therapeutic response.

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.

[Papular drug eruption along the lines of Blaschko caused by lenalidomide]. / Papulöse Arzneimittelreaktion entlang der Blaschko-Linien durch Lenalidomid.

Cutaneous drug reactions can take many forms. In rare cases these reactions can occur along the lines of Blaschko. A 60-year-old patient received lenalidomide in 3-weeks-cycles for the treatment of a plasmocytoma. After four months of treatment, red papules appeared on the extremities and the trunk following the lines of Blaschko. The lesions nearly disappeared during drug-free intervals and appeared with renewed intensity after restart of a therapy cycle.

Hyperkeratotic eruption, hand-foot skin reaction, facial erythema, and stomatitis secondary to multi-targeted kinase inhibitor sorafenib.

BACKGROUND: Sorafenib and sunitinib, novel anti-tumor agents approved for the treatment of renal cell carcinoma, have been associated with multiple adverse cutaneous effects. OBJECTIVE: To further investigate the constellation of possible adverse effects of sorafenib and sunitinib on the skin. SUBJECTS AND METHODS: Case report of a 62 year old male with history of renal cell carcinoma treated with adjuvant sorafenib. RESULTS: Our patient experienced a diffuse hyperkeratotic rash, hand-foot skin reaction, facial erythema, and stomatitis within three weeks of initiation of sorafenib. CONCLUSION: Further investigation regarding the possible adverse cutaneous effects of sorafenib and sunitinib, pathogenesis and risk factors for development, associated time course, and preventative and therapeutic methods, will allow for better patient and physician education.

[Cutaneous events during anti-TNF alpha therapy: a prospective observational study of 41 cases]. / Evénements cutanéomuqueux au cours des traitements par anti-TNF alpha : étude observationnelle prospective de 41 cas.

BACKGROUND: The cutaneous adverse effects of TNFalpha inhibitors and their potential implication in the onset of associated dermatoses remain poorly understood. PURPOSE: To describe the different clinical dermatological situations seen in patients treated with TNFalpha inhibitors. PATIENTS AND METHODS: We conducted a prospective, observational study of patients followed at the Dermatology Department of the CHU Nord university teaching hospital of Marseilles. All patients, referred by various departments, were treated with TNFalpha inhibitors and presented cutaneous events. RESULTS: Forty-one patients were included in the study. Various cutaneous manifestations were observed, including: 15 psoriatic rashes, six skin infections, three eczema rashes, three cases of lupic syndrome, two anaphylactic reactions to infusion and two cutaneous drug reactions. An original case of parapsoriasis was observed. Cutaneous tumors are rarely described. DISCUSSION: This study confirms the multiple clinical dermatological situations observed in patients treated with TNFalpha inhibitors and illustrates the need for good coordination between dermatologists and other specialists in order to ensure optimal management of this population.

Drug-induced papuloerythroderma: analysis of T-cell populations and a literature review.

Papuloerythroderma of Ofuji is characterized by coalescent solid papules that spare the skin folds. Although cutaneous lymphomas and internal malignancies are known associated conditions, the causative agents are unclear in most cases. A number of recent reports have documente d that drugs can induce papuloerythroderma. We review ed the reported cases and our own cases of drug-induc ed papulo erythroderma, together with our data from lympho cyte transformation tests and T-cell subsets of peri pheral blood. All of the 9 patients were male, and the causative drugs were various. Provocation tests were positive in all 6 patients examined. Whereas drug patch tests were negative in all 5 cases tested, the patients' peripheral blood lymphocytes responded well to the culprit drug in 4 of 5 patients tested. The patients had higher percentages of circulating CCR4+CD4+ T helper (Th) 2 cells than CXCR3+CD4+ Th1 cells. Drug-induced papuloerythroderma seems to be mediated by Th2 cells reacting with the causative drug.

Ioversol-induced acute generalized exanthematous pustulosis: a case report.

BACKGROUND: Acute generalized exanthematous pustulosis (AGEP) is a relatively rare exfoliative dermatosis consisting of a generalized eruption of sterile, nonfollicular pustules arising on widespread erythematous and edematous skin that is usually caused by drugs. It has an acute onset, and patients often have systemic manifestations, including leukocytosis, fever, and hemodynamic instability. Rarely has AGEP been associated with radiocontrast dyes. OBSERVATIONS: We describe an 84-year-old man who developed AGEP on 2 separate occasions after receiving an infusion of an ioversol-containing radiocontrast dye. Conclusion Acute generalized exanthematous pustulosis may occur after the use of intravenous radiocontrast dye.

Acute generalized exanthematous pustulosis due to clindamycin.

Acute generalized exanthematous pustulosis (AGEP) is a rare skin eruption most commonly caused by medications. It is characterized by fever and the acute eruption of non-follicular pustules overlying erythrodermic skin. Histopathology shows subcorneal pustules with a background of dermal edema and spongiosis, leukocytoclastic vasculitis, perivascular eosinophils, and focal necrosis of keratinocytes. Three cases of clindamycin induced AGEP have been reported in the literature. A case of AGEP due to clindamycin is reported in a patient with numerous other drug allergies and without history of psoriasis. Presentation and treatment of AGEP are reviewed.