March 2005

Discussion:
Used as a chemotherapeutic agent, bleomycin is a cytotoxic antibiotic. Side effects (as with other chemotherapeutic agents) include alopecia, nail changes (Beau's lines, onycholysis, onychodystrophy, and pigmented bands), and stomatitis. Other reported adverse effects include verrucous plaques on the elbows and knees, painful nodules on the fingers, and blistering. Flagellate hyperpigmentation is unique to bleomycin.

Hyperpigmentation from systemic bleomycin occurs in 8-20% of patients on treatment. It usually appears after cumulative doses of 90-285 mg, but it may occur at very low doses. Flagellate hyperpigmentation may appear from 1 day to 9 weeks after treatment initiation. It occurs most commonly on the chest and back, but it may also be seen on the small joints of the hands, elbows, and knees. Pruritus or urticarial plaques may precede the hyperpigmentation. Sclerodermoid changes have been reported.

The pathogenesis is not fully understood. It may represent a form of postinflammatory hyperpigmentation, a drug-induced local melanogenesis, or an alternation of "pigment maturation." The hyperpigmentation is reversible upon discontinuation of the drug; it fades within 3-4 months. Topical steroids and oral antihistamines are used to alleviate pruritus.

References:
1. Fitzpatrick's Dermatology in General Medicine, 5th ed. (Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI eds.). New York: McGraw-Hill, 1999. p 1002.
2. Dermatology (Bolognia JL, Jorizzo JL, and Rapini RP eds.). London: Mosby, 2003. pp 992-3.

This case is presented by Dr. Helen Kim-James.