Flagellate Erythema Secondary to Bleomycin: A New Case Report and Review of the Literature

August 2014 | Volume 13 | Issue 8 | Case Reports | 983 | Copyright © August 2014

Mohamed Réda Khmamouche MD,a,b Adil Debbagh MD,a Tarik Mahfoud MD,b Rachid Aassab MD,a
Siham Lkhoyaali MD,a Mohamed Ichou MD,b and Hassan Errihani MDa

aDepartment of Medical Oncology, National Institute of Oncology, Rabat, Morocco
bDepartment of Medical Oncology, Military Hospital Mohammed V, Rabat, Morocco

Bleomycin is an antibiotic with antineoplastic properties. It is used in the treatment of different tumors in oncology. The mucocutaneous side effects of this drug include ulcers, scaly erythematous and bullous lesions, sclerosis, stomatitis, and pigmentary alterations. Flagellate erythema is a characteristic hyperpigmentation of bleomycin. We report a case of flagellate erythema following the administration of bleomycin in a 34-year-old woman with ovarian teratoma. She developed linear lesions two weeks after the first injection of bleomycin. Flagellate erythema is a specific reaction to bleomycin therapy, which occurs in susceptible individuals independently of dose, route of administration, and type of malignant disease treated.

J Drugs Dermatol. 2014;13(8):983-984.


Bleomycin is an antibiotic with an antineoplasic property. It is used in the treatment of different malignant tumors, including testes carcinoma, head and neck squamous cell carcinoma, lymphomas, Kaposi sarcoma, and malignant pleural effusion.1 The toxicity affects the skin and the lung. The frequent cutaneous effects induced by bleomycin are erythema, rash, striae, and hyperpigmentation, which are reported in approximately 50% of treated patients.
Hyperkeratosis, nail changes, alopecia, pruritus, scleroderma, like skin changes and stomatitis have also been reported. However, linear skin pigmentation occurs during bleomycin use. This side effect was described for the first time in 1971 by Moulin et al,2 and is named flagellate dermatitis or flagellate erythema, a prominent characteristic from this drug.2


A 34-year-old caucasian woman, with no antecedents, was diagnosed with ovarian teratoma stage IV (multiple peritoneal metastasis). After surgery, she was given combination of chemotherapy intravenously with BEP regimen: bleomycin with a weekly administration of 30 mg at day 1, day 8, day 15, and etoposide of 500mg/m2 from day 1 to day 5 and 100mg/m2 of cisplatin at day 1. After 1 cycle (90 mg of bleomycin), the patient was presented to our department with linear pigmentation of the chest and the upper part of the dorsum with a flagellate aspect (Figure 1). Antihistamines and corticotherapy were prescribed, resulting in the disappearance of the pruritus. The patient continued her chemotherapy with bleomycin and she retains linear scar pigmentation after four cycles of treatment.


Bleomycin is a mixture of cytotoxic polypeptid antibiotics isolated from Streptomyces verticillus discovered in 1965 by Umezawa.2,3,4 It is freely soluble in water. It used as an antineoplasic drug alone or in association with other cytotoxics for treatment of variety types of malignant tumors.1 In low concentrations, bleomycin has a cytostatic effect by inhibition of mitosis and, in high doses, it blocks the incorporation of thymidine into the DNA causing DNA fragmentation into smaller fractions. Thus, the drug stops the S- phase of the cell cycle and cleaves of DNA.2,3
Bleomycin is associated with some toxicities. Mucocutaneous side effects commonly seen with this drug includes ulcers, scaly erythematous and bullous lesions, sclerosis, nail changes, stomatitis, alopecia, glossitis, and pigmentary alterations.5 Hyperpigmentation, painful inflammatory nodules on fingers and scleroderma plaques are the more side effects characteristic of bleomycin.4,6,7 Flagellate erythema, also called flagellate dermatitis, is a linear pigmentation described for the first time in 1971 by Moulin et al,2 and was considered to be very specific to bleomycin.
It occurs independently of the dose, route of administration (intravenous, intrapleural, intraperitoneal,8 intralesionally9)and the type of the treated tumor.9,10 Generally, these lesions appeared after a cumulative dose of 90 to 285 mg but some cases are reported with doses as low as 15mg.4,8 This lesion complicate treatment with bleomycin in 20-30% of cases.11,12 The interval between the beginning of the treatment and the appearance of the flagellate erythemay varies from a few hours up to 9 weeks3,4 and may persist for up to six months.10