Sir,
Eruptive melanocytic nevi, the abrupt development of multiple melanocytic nevi over weeks to months often in association with an underlying trigger, were first described by Hutchinson in 1868.[1] This condition has commonly been linked to cases of severe blistering skin diseases and compromised immunity.
The evolution of biological agents has resulted in increasing incidence of eruptive nevi associated with medications (ENAMs), which involves the development of at least one of the following conditions during a 6-month period in association with medication use: (1) >5 melanocytic nevi on palmoplantar surfaces at any age, (2) >10 melanocytic nevi over the body for nonpubescent or pregnant individuals, and (3) >20 melanocytic nevi for pubescent or pregnant individuals.[2] Herein, we report a case of eruptive melanocytic lesions associated with sorafenib.
A 60-year-old Asian woman was prescribed 400 mg of sorafenib (Nexavar) orally twice daily for metastatic thyroid papillary carcinoma treatment. After 1 month of sorafenib treatment, she noticed new blackish maculopapules on her face and extremities [Figure 1]. Histologic examination of a glabellar lesion indicated an atypical junctional melanocytic nevus with slight architectural and cytological atypia [Figure 2] and that of a right foot lesion revealed a junctional melanocytic nevus. A diagnosis of sorafenib-related eruptive melanocytic nevi was made. The number of lesions continued to increase, and further skin biopsy revealed interface dermatitis with basal hyperpigmentation at the left eyebrow and basal hyperpigmentation alone at the right eyebrow and left temple.
Figure 1.
One month after sorafenib treatment, the patient presented with progressive new blackish maculopapules on her face and extremities
Figure 2.
(a) Glabella biopsy specimen shows small nests of melanocytes at the dermoepidermal junction with focal bridging. (Hematoxylin-Eosin stain, original magnitication x 200); (b) Higher magnification of the glabella biopsy specimen shows some melanocytes have enlarged vesicular or slightly hyperchromatic nuclei. (hematoxylin-eosin stain, original magnitication x 400); (c) Foot biopsy specimen shows small nests of normal melanocytes at the dermoepidermal junction (hematoxylin-eosin stain, original magnitication x 200); (d) Foot biopsy specimen (hematoxylin-eosin stain, original magnitication x 400)
Due to cancer progress, anticancer medication was change to lenvatinib (Lenvima®). After 2 years follow-up, no new pigmented lesion developed.
Sorafenib, an oral multikinase inhibitor, is licensed for the treatment of renal cell carcinoma and hepatocellular carcinoma at a dose of 400 mg twice daily. Sorafenib-induced cutaneous adverse reactions commonly appear on hand or foot skin reactions, facial erythema, subungual hemorrhages, alopecia, xerosis, exanthematous eruptions, squamous cell carcinoma, and keratoacanthoma. Eight cases of sorafenib-induced eruptive melanocytic lesions have also been reported.[3] In the current case, the number of pigmented lesions over the patient's face and extremities increased rapidly. Skin biopsy revealed various types of pathologic changes.
A high number of common melanocytic nevi are an independent risk factor for melanoma.[4] Similarly, eruptive nevi with a high number of melanocytic lesions may be a risk factor; however, this proposition requires further data for validation.
Histologically atypical melanocytic nevi are also considered to represent an independent risk factor for melanoma. However, dysplastic nevi in the setting of ENAMs have rarely been reported.[5] Therefore, strict dermatologic follow-up for melanocytic lesions is recommended for all patients presenting with ENAMs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
The authors would like to thank the patient whose case has been reported.
References
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