Bleomycin induced hyperpigmentation of skin

A 64-year-old gentleman, a known case of Hodgkin's lymphoma on ABVD chemotherapy regimen (Doxorubicin, Bleomycin, Vinblastine, Dacarbazine), presented with blackish discoloration of skin for two weeks. He had received three cycles of chemotherapy over 12 weeks, including 54 mg/m² of intra-venous bleomycin. His B symptoms had completely disappeared after chemotherapy and there were no new symptoms. Clinical examination showed diffuse dark brown hyper-pigmentation of skin involving whole body with the changes being more conspicuous in areas exposed to the sun such as the limbs and face (Figure 1A–D). He was counseled about the likely effect of the drug on the skin. It was agreed to complete the planned six cycles of therapy. Two months after chemotherapy the pigmentation had markedly reduced (Figure 1E–H).

Figure 1
A–D: Clinical photograph of the patient showing hyperpigmentation of skin involving face, hand and foot. E–H: Repeat clinical photograph of the patient showing near complete resolution of the hyperpigmentation of affected areas.

Bleomycin is known to cause lung and skin toxicity due to relative absence of hydrolase in skin tissue resulting in decreased metabolism and delayed clearance.¹ Pulmonary complications are common but skin changes are rare and include hyper-pigmentation, plaques, hyperkeratotic lesions, erythema multiforme, alopecia, stomatitis and nail changes.² The exact mechanism of skin changes caused by bleomycin is not known. The treatment involves management of underlying disorders or withdrawal of the offending drug.³

References

• ¹
  Gupta LK, Tanwar RK, Khare AK, Jain SK. Bleomycin induced flagellate pigmentation. Indian J Dermatol Venereol Leprol. 2002;68(3):158-9.
• ²
  Verma SP, Subbiah A, Kolar Vishwanath V, Dutta TK. Bleomycin-induced skin toxicity: is it always flagellate erythema? BMJ Case Rep. 2016;2016, pii:bcr2014204575.
• ³
  Chen YB, Rahemtullah A, Breeden E, Hochberg EP. Bleomycin-induced flagellate erythema. J Clin Oncol. 2007;25(7):898-900.

Publication Dates

• Publication in this collection
  Jan-Mar 2018

History

• Received
  29 June 2017
• Accepted
  21 Aug 2017