Volume 20 Number 1 January 2014 Case Presentation Eruptive purpuric papules on the arms; a case of chemotherapy-induced inflammation of actinic keratoses and review of the literature

Cindy Chambers, Helen Liu, Clifton White, Kevin White, Victoria Sharon, Victoria Sharon
unpublished
Chemotherapy-induced inflammation of actinic keratosis can present in patients with subclinical actinic keratoses that become erythematous and pruritic within weeks of initiating systemic chemotherapy. The reaction is limited to sun-exposed areas and, classically, histologic findings of parakeratosis and epidermal necrosis with keratinocyte nuclear pleomorphism are present. Exuberant reactions with extensive epidermal necrosis may lead to subepidermal vesiculation. We report a case of a
more » ... a case of a 67-year-old man with a history of chronic hepatitis B virus infection and recently diagnosed squamous cell carcinoma of the lung who was noted to have progressive asymptomatic violaceous papules on the extensor forearms and distal upper arms while hospitalized for possible sepsis following initiation of chemotherapy. A dermatology consulatation was requested to rule out possible vasculitis. It is important to recognize chemotherapy-induced inflammation of actinic keratoses in predisposed patients; it may be managed successfully with topical corticosteroids and does not necessitate discontinuation of the offending chemotherapeutic agent. A 67-year-old man with a history of chronic hepatitis B virus infection and recently diagnosed squamous cell carcinoma of the lung was noted to have asymptomatic violaceous papules of the extensor forearms and distal upper arms while hospitalized for possible sepsis following initiation of chemotherapy. The lesions started two weeks after chemotherapy with carboplatin and paclitaxel, and appeared as "bruise-like" red macules that gradually evolved into purpuric papules over the course of one week. The inpatient Dermatology service was consulted to rule out possible vasculitis. Review of systems was negative for arthralgia, abdominal pain, hematochezia, and hematuria. Physical examination revealed multiple dark red macules, purpuric papules, and occasional hemorrhagic vesicles limited to the bilateral extensor forearms, distal upper arms, and dorsal hands (Figure 1). In contrast to the upper extremities, the patient did not have extensive sun damage of the face or other common photoexposed sites. The remainder of the skin examination was unremarkable. A punch biopsy was obtained from a papule on the right forearm for routine histopathologic examination (Figure 2 and Figure 3).
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