Lichenoid Dermatitis From Interferon alpha-2a in a Patient With Metastatic Renal Cell Carcinoma and Seronegative HCV

A 71-year-old Caucasian man with hypertension, diabetes, hypercholesterolemia, and metastatic renal cell carcinoma (RCC) presented to clinic 2 months after starting interferon-alpha 2a with diffuse, slightly pruritic lesions on trunks and extremities. The 3 million units daily interferon-alpha 2a was treatment for his metastatic RCC. The eruption started on his back and chest and progressed to the extremities. His other medications included Norvasc, Lipitor, Lotensin, and Glyburide. The patient had been on all the medication for years except for the addition of glyburide 8 months prior to the eruption. Hepatitis B and C panel were nonreactive. On physical exam, the patient had diffuse macules and papules on the chest, upper back, and extremities that excluded the face, oral mucosa, conjunctiva, genitalia, palms, soles, inner aspect of arms, or back of thighs (Figure 1). The trunk lesions were scaly, erythematous lesions while the dorsal extremities demonstrated hyper-pigmented, violaceous polygonal plaques and papules with a whitish surface (Figure 2).Histopathology of biopsy sites from the forearm and mid-back revealed lichenoid dermatitis with lymphocytic infiltrate, saw-tooth rete ridges, hypergranulosis, numerous civatte bodies, and rare necrotic keratinocytes. There was only focal parakeratosis in specimen from mid back and eosinophils were not readily identified (Figure 3).The patient was treated with a high potency topical corticosteroid cream and with no resolution of the lesions. No further treatment was initiated, as the lesions were not symptomatic for the patient. However, the interferon-alpha 2a was discontinued after 5.5 months, as the tumor was unresponsive to treatment. The lesions had cleared completely at 4 months after interferon was stopped. All four medications were continued while interferon was discontinued and the lesions resolved. The patient passed away from metastatic RCC 5 months after.

Drug induced cutaneous eruptions from interferon are estimated to occur anywhere from 13% to 23%.1 These can include injection site reaction, eczematous drug reactions, alopecia, sarcoidosis, lupus, and lichenoid drug reaction (LDE).¹ Many cases of drug induced cutaneous eruptions with interferon are associated with chronic hepatitis C, including a lichenoid eruption.²Literature review of lichenoid drug reaction to interferon revealed although there has been case reports of interferon-induced lichen planus in seronegative HCV patients with lymphoproliferative disorders and melanoma, this is the first case report in a patient with metastatic RCC.^3-5A lichenoid drug eruption (LDE) can be difficult to diagnosis from idiopathic lichen planus because they share common clinical and histological characteristics.⁶ The LDE appears after a period of few weeks to several months of starting a variety of drugs. Clinically, it typically presents as pruritic, violaceous papules and plaques.⁷ The duration and dosage of the drug and specific patient characteristics can influence the LDE.⁸ The eruption may occur more rapidly with re-introduction of the offending drug.⁸ Classically, LDE occurs in a symmetrical outbreak involving the trunk and extremities, with sparing of the mucosal surfaces.⁹ Although mucosal involvement is less