Flagellate erythema due to bleomycin

Abstract

A 48-year-old woman, recently diagnosed with classical Hodgkin lymphoma stage 3B, developed an intensely itchy rash 1 week after her first cycle of doxorubicin, bleomycin, vincristine, dacarbazine (ABVD) chemotherapy. The eruption subsided with a course of prednisolone 40 mg daily for 4 d, but recurred after the third chemotherapy cycle, despite the omission of bleomycin. She was referred to dermatology at this stage. Examination showed an extensive violaceous and erythematous excoriated rash with a striking linear configuration and post-inflammatory hyperpigmentation, typical of flagellate erythema. Clobetasol proprionate cream twice daily was prescribed with good response. After 1 week, the inflammatory lesions had settled, leaving residual hyperpigmentation that was expected to settle with time. There has been no recurrence at 3 months follow-up. Flagellate erythema is a cutaneous side effect of bleomycin or its derivative peplomycin. The term ‘flagellate’ derives from the Latin flagellum, referring to the characteristic whip-like appearance. It is also rarely associated with ingestion of shiitake mushrooms, dermatomyositis and adult-onset Still’s disease. All methods of administration of bleomycin may cause the rash, occurring from 12 h to as long as 6 months after drug administration. The rash usually subsides 3–4 months following discontinuation of the drug. It is unusual that our patient had a relapse after chemotherapy omitting bleomycin, suggesting a possible unusual recall phenomenon, particularly as flagellate erythema has not been described with the other drugs in the ABVD regime. Treatment includes topical or systemic corticosteroids and oral antihistamines. The length of treatment depends on clinical response. The mechanism for the peculiar linear nature of this reaction remains uncertain.