INTRODUCTION
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
CASE REPORT
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.
DISCUSSION
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
