As the use of new chemotherapeutic agents becomes
more common, the associated side effects increase.
Sorafenib tosylate (Nexavar® tablets, Bayer Healthcare
Pharmaceuticals Inc.) is approved for use in the treatment
of unresectable hepatocellular carcinoma (HCC),
advanced renal cell carcinoma, and locally recurrent or
metastatic, progressive, differentiated thyroid carcinoma
refractory to radioactive iodine treatment. It inhibits tyrosine
kinase receptors such as vascular endothelial growth
factor, platelet-derived growth factor, cKit, and Raf kinases.
Although some cutaneous side effects of sorafenib are well
described, a possible association of psoriasiform eruption
and sorafenib has been reported more recently.1-6 We present
herein another patient who developed cutaneous psoriatic
lesions following sorafenib therapy.
A 69-year-old man with a history of HCC presented to our dermatology
clinic with a complaint of scaly erythematous lesions
on the trunk and extremities. He had a 40-year history of stable
mild-to-moderate localized plaque-type psoriasis that was
in remission for at least 10 years. After surgical resection of
HCC, sorafenib (400 mg twice daily orally) was initiated due to
the lung metastases. Ten days after the drug was started, scaly
erythematous papules developed on his elbows. A skin biopsy
showed confluent parakeratosis, hypogranulosis, suprapapiller
thinning, psoriasiform hyperplasia, and proliferating congested
capillaries in elevated papilla. These changes are all consistent
with classical psoriasis. Then, discontinuation of sorafenib for
one month was recommended by the Department of Oncology.
When drug was taken again, multiple guttate erythematous
papules and plaques scattered gradually over his trunk, knees,
and arms (Figure 1). Biopsy taken from a femoral papule
showed confluent parakeratosis, hypogranulosis, Munro microabscesses,
intraspinous neutrophils, suprapapiller thinning
of epidermis, and psoriasiform epidermal hyperplasia, a few
necrotic keratinocytes, as well as superficial perivascular lymphocytes
and many eosinophils in the dermis (Figure 2). His
lesions improved significantly two weeks after treatment with
clobetasol 17-propionate ointment and narrow-band UVB phototherapy,
while sorafenib was discontinued.
Sorafenib is usually well tolerated, however, various cutaneous
side effects including hand-foot skin reaction, facial erythema,
acral erythema, alopecia, xerosis, a non-specific exanthem,
stomatitis, and subungual splinter hemorrhages have been
frequently reported. Less commonly, multiple squamous cell
carcinoma, keratoacanthoma, eruptive melanocytic lesions,
and epidermoid cysts have also been described. Even though
cutaneous toxicities are not usually life threatening, they may
lead to dose modification or discontinuation of critical antineoplastic
therapy. On the other hand, a recent study indicated that
patients with sorafenib-related cutaneous reactions might be
associated with a good survival prognosis in HCC, and therefore
early identification and management of these reactions
might be critical for continuing sorafenib therapy.7
