Table I.
Epidemiologic and clinicopathologic findings in the 6 cases
| Case | Age/sex | Malignancy | Prior therapy | Most recent therapy∗ | Onset of rash (season and chemotherapy cycle) | Clinical findings | Histologic findings | Course and response |
|---|---|---|---|---|---|---|---|---|
| 1 | 60 F | AML: 47,XX, +8, t(9;11) | None | Decitabine priming with “7+3” cytarabine and daunorubicin | Autumn, cycle 1 | Tender erythematous patches in the bilateral inframammary folds, left axilla, left anterior chest, and cervical skin folds | Atrophic epidermis with prominent interface changes displaying a hydropic pattern of the basal keratinocytes, early squamous metaplasia of the dermal eccrine ducts, and superficial and perivascular lymphocytic inflammatory infiltrate, consistent with interface dermatitis with early associated changes of squamous syringometaplasia | Complete re-epithelialization achieved after application of topical steroids, silver-impregnated mesh gauze, and aluminum acetate soaks |
| 2 | 43 F | Metastatic rectal adenocarcinoma and renal cell carcinoma | Surgical debulking | FOLFIRI and bevacizumab | Summer, cycle 3 (interrupted because of nausea and vomiting) | Tender, sharply demarcated hyperpigmented and erythematous scaly patches in the inframammary regions and inguinal folds bilaterally, with focal serous crusting in the right inframammary patch | Prominent compact hyperkeratosis of the epidermis with patchy parakeratosis and focal ulceration with a mild chronic inflammatory infiltrate admixed with occasional neutrophils and some impetiginization; mild, predominantly perivascular and periadnexal chronic inflammatory infiltrate in the dermis | Initially treated for suspected cutaneous candidiasis, cellulitis, and ACD without improvement. Treatment included nystatin cream, fluconazole (both topical powder and oral), empiric IV antibiotics, and topical corticosteroids. Astringent soaks and higher-potency topical steroids resulted in initial improvement. |
| 3 | 68 F | Metastatic breast carcinoma: ER+, PR+, Her-2/neu- | Lumpectomy with axillary node dissection, adjuvant external beam radiation, doxorubicin and cyclophosphamide, paclitaxel, anastrozole, docetaxel, fulvestrant, letrozole, capecitabine | Doxorubicin | Summer, cycle 2 | Extensive hyperpigmentation and exquisitely tender, erythematous rash with thin scale on the buttocks, posterior thighs, and inframmamory regions | Interface dermatitis with keratinocyte necrosis and associated squamous syringometaplasia, marked surface hyperorthokeratosis, and superficial and perivascular lymphocytic and histiocytic inflammation | Treated with topical corticosteroids with lidocaine and an oral prednisone taper with subsequent improvement. Patient discontinued cytotoxic chemotherapy because of severity of the skin reaction and was restarted on hormonal agents |
| 4 | 26 M | Recurrent HL | ABVD | GND | Winter, cycle 2 | Erythematous and dusky papules and plaques intermixed with erosions on the bilateral antecubital fossae, umbilicus, and groin with crusting of the scrotum. Dusky erythema of the palmar and dorsal surfaces of the bilateral hands without evidence of oral mucositis | No biopsy performed | Initially treated for suspected cellulitis with TMP-SMX with subsequent worsening of rash. Supportive treatment with magic mouthwash and aluminum acetate soaks resulted in improvement. |
| 5 | 52 F | Metastatic ovarian adenocarcinoma | Neoadjuvant carboplatin and paclitaxel, surgical debulking, and adjuvant carboplatin and paclitaxel | Experimental trial of doxorubicin and study drug VTX-2337 | Summer, cycle 4 | Painful, dusky plaques on the upper abdomen; large, erythematous erosions and desquamation on the bilateral posterior thighs, and scattered follicular erythematous papules on the bilateral anterosuperior thighs | Interface dermatitis with alternating hyper- and hypokeratosis, clusters of neutrophils and parakeratosis in the stratum corneum, lymphoid cells at the dermal-epidermal junction with focal interface reaction, and a superficial and deep dermal, predominantly perivascular and periadnexal chronic inflammatory infiltrate admixed with rare eosinophils | Initially treated for suspected atypical SJS with pulse-dosed IV steroids, topical steroids, topical mupirocin, and aggressive pain control with gradual improvement over weeks |
| 6 | 60 F | Metastatic renal cell carcinoma | Nephrectomy, pazopanib, cabozantinib | Axitinib | Winter, cycle 1 | Well-demarcated erythema of the intertriginous zones of the panniculus, axillae and perineum with several erosions draining serous fluid | Parakeratosis, mild perivascular dermatitis with red blood cell extravasation; eccrine squamous syringometaplasia identified in several sections | Initially treated with antimicrobial silver complex moisture wicking fabric. Axitinib was stopped. Wounds improved over several days, but patient switched to comfort care because of disease progression. |
AML, Acute myelogenous leukemia; FOLFIRI, leucovorin, 5-fluorouracil, and irinotecan; ACD, allergic contact dermatitis; IV, intravenous; ER, estrogen receptor; PR, progesterone receptor; HL, Hodgkin's lymphoma; ABVD, doxorubicin, bleomycin, vinblastine, and dacarbazine; GND, gemcitabine, Navelbine, and doxorubicin; TMP-SMX, trimethoprim-sulfamethoxazole; SJS, Stevens-Johnson syndrome.
∗
Before or during development of rash.