Mucocutaneous reactions to chemotherapy

Abstract

We read with great interest the CME article entitled “Mucocutaneous Reactions to Chemotherapy” by Wendy S. Susser, MD, Diane L. Whitaker-Worth, MD, and Jane M. Grant-Kels, MD, in the March 1999 issue of the Journal (1999;40:367-98). However, there are two statements made by the authors that we would like to comment on. First, the authors state in their discussion of eccrine squamous syringometaplasia (ESS): “The clinical presentation is similar to that of NEH [neutrophilic eccrine hidradenitis] with erythematous macules, papules, plaques, or vesicles that may be localized or generalized” (page 386), and they cite two of our articles.1Valks R Buezo GF Dauden E Fraga J García-Díez A Eccrine squamous syringometaplasia in intertriginous areas.Br J Dermatol. 1996; 134: 984-986Crossref PubMed Scopus (26) Google Scholar, 2Valks R Fraga J Porras-Luque J Figuera A García-Díez A Fernández-Herrera J Chemotherapy-induced eccrine squamous syringometaplasia.Arch Dermatol. 1997; 133: 873-878Crossref PubMed Google Scholar Although we agree that ESS and NEH may be observed in similar clinical lesions, the special interest of our patients was the peculiar distribution of the eruption. In fact, we described a distinctive eruption in 10 patients with ESS, which was characterized by a predominant involvement of the axillae, groins, and/or palms and soles.2Valks R Fraga J Porras-Luque J Figuera A García-Díez A Fernández-Herrera J Chemotherapy-induced eccrine squamous syringometaplasia.Arch Dermatol. 1997; 133: 873-878Crossref PubMed Google Scholar The article comprises the largest series of cases of chemotherapy-induced ESS and reports a clinicopathologic correlation between the histologic finding of ESS and the cutaneous lesions in sites, which contain high numbers of eccrine glands and/or represent natural sites of occlusion of sweat. This observation highlights the connection between the concentration of chemotherapy in eccrine sweat and subsequent clinical and histologic changes in skin.3Horn TD Antineoplastic chemotherapy, sweat, and the skin.Arch Dermatol. 1997; 133: 905-906Crossref PubMed Google Scholar Second, the authors state in their discussion of the pathogenesis of acral erythema that “…microscopic damage to the eccrine glands or ducts has never been detected.” (page 377) However, in 1991 Rongioletti et al4Rongioletti F Ballestrero A Bogliolo F Rebora A Necrotizing eccrine squamous syringometaplasia presenting as acral erythema.J Cutan Pathol. 1991; 18: 453-456Crossref PubMed Scopus (31) Google Scholar described a patient who had typical acral erythema with histopathologic ESS. In addition, in our series of 10 patients with ESS cited above,2Valks R Fraga J Porras-Luque J Figuera A García-Díez A Fernández-Herrera J Chemotherapy-induced eccrine squamous syringometaplasia.Arch Dermatol. 1997; 133: 873-878Crossref PubMed Google Scholar 5 patients also exhibited acral erythema. Finally, Santa Cruz et al5Santa Cruz DJ Samuels LE Bauer EA Phillips GL Herzig GP Epidermal dystrophy: clinicopathologic study of chemotherapeutic agent toxicity in ten patients.Lab Invest. 1982; 46: 72Google Scholar observed ESS in a palmar and plantar eruption after high-dose chemotherapy and/or radiotherapy, which they named “epidermal dystrophy.” The reason that many reports of acral erythema fail to describe alterations of the eccrine glands or ducts is partly explained by inadequately performed histologic studies. Most of the cited reports lack any reference of the eccrine glands or ducts in their histopathologic descriptions or simply do not include a histologic examination at all. Another factor may be the inadequate size and depth of the biopsy specimens obtained in some studies without sufficient dermal tissue to evaluate the eccrine glands or ducts. Most reports did not describe the size of the biopsy specimen or show the eccrine glands in the photomicrographs. Nevertheless, the lack of damage to the eccrine glands or ducts in reports in which an adequate biopsy specimen was obtained suggests the existence of alternative or additional pathophysiologic mechanisms in acral erythema. It may also reflect an individual or drug-related response of the eccrine glands or ducts. 16/8/103186 doi:10.1067/mjd.2000.103186