Lesser known evil of a commonly used devil-bleomycin induced flagellate dermatitis.

Sir,

A 27-year-old male presented to us with the history of right high inguinal orchidectomy for a testicular swelling, 6 months prior to presentation, diagnosed of malignant mixed germ cell tumor of the testis. We evaluated him and found to have abdominal lymphadenopathy and gave him four cycles of adjuvant chemotherapy with cisplatin, bleomycin, and etoposide. While on this chemotherapy, he developed multiple skin lesions all over upper half of body. Cutaneous examination revealed near total alopecia with multiple erythematous, hyperpigmented streaks (flagellate appearance) over the truck, neck, and upper limbs [Figure 1]. He was thus clinically diagnosed to have bleomycin induced flagellate dermatosis.

Figure 1

Skin lesions due to bleomycin

Bleomycin is a glycopeptide used in oncology as a chemotherapeutic agent for Hodgkins disease, germ cell tumors, and pleurodesis of malignant pleural effusions. Though the pulmonary toxicity of bleomycin is well known, its cutaneous side effects are uncommon. The cutaneous effects of bleomcyin range from generalized hyperpigmentation, sclerodermoid changes, erythema multiforme, gangrene, to flagellate dermatosis.[1] First reported in 1970,[2] the incidence of bleomycin induced flagellate dermatosis varies from 8 to 20%.[3] The exact mechanism of bleomycin induced flagellate dermatosis is unclear and is hypothesized to be due to raised local levels of the drug in the skin.[4] This in turn is due to low levels of bleomycin hydrolase in the skin.[5] There is no specific treatment for bleomycin induced flagellate dermatosis and the skin lesions are usually self-limiting.