Journal of Dermatology 2017; 44: e95–e96
LETTER TO THE EDITOR
Bromoderma in a pituitary adenoma patient treated with bromocriptine Dear Editor, Bromoderma is a halogenoderma caused by exposure to bromide-containing drugs and shows similar symptoms as acne or pyoderma.1 Although the frequency of bromide therapy for refractory epilepsy is decreased, bromide-containing drugs are often used for several diseases.2 To our knowledge, the current case is the first one of bromoderma associated with bromocriptine. A 66-year-old man was treated for pituitary adenoma with bromocriptine including bromide for 20 years. Because he noticed erythema and ulcer on the left side of the abdomen 1 month prior, he was admitted to our hospital. A physical examination showed a painful erythema with necrotic ulcer on the left side of the abdomen and acne-like rash on the right upper lip and trunk (Fig. 1a). There was no fever, joint pain, oral/genital ulcer or abnormal ophthalmologic finding. Needle reaction was positive. Laboratory findings revealed the following values: white blood cell count, 10800/mm3 (85% neutrophils); C-reactive protein, 11.34 mg/mL; chloride, 103 mEq/L; and antinuclear antibody, rheumatoid factor, anti-desmoglein 1 and 3 antibodies were negative. Skin swabs for microbiology identified no growth of bacteria or fungus. Whole blood bromide level was 485 lg/mL (normal level, not detected; half-life, 12 days) at 7 days after the discontinuation of bromocriptine. During bromocriptine treatment, his bromide level was estimated to be of non-toxic concentration but therapeutic concentration by half-life. A biopsy specimen showed ulcer, perifolliculitis and dense inflammatory infiltration in the dermis.
(a)
(b)
In addition, the infiltration consisted of many neutrophils, and some eosinophils, histiocytes and lymphocytes (Fig. 1b–c). Therefore, we diagnosed the case as bromoderma because of clinical findings, administration of a bromide-containing drug and elevated blood bromide levels. Hyperchloremia is one of the laboratory findings of bromoderma,3 but it was normal. He was treated with the discontinuation of bromocriptine and the initiation of oral potassium iodide (0.9 g/day), topical clobetasol propionate ointment and silver sulfadiazine cream. His eruptions were gradually improved within 1 month. Six months after our cure, his physical symptoms resolved completely. Bromoderma is a rare cutaneous reaction induced by bromide-containing drugs such as anti-epileptics, analgesics and hypnotics.1 Cutaneous manifestations of bromoderma are exudative plaques, fungating nodules, necrotic ulcers and acneiform eruptions.1 Pathological findings show pseudo-carcinomatous hyperplasia in the epidermis, thick infiltration of neutrophils and abscess formation in the dermis.4 The major cellular components are neutrophils activated by bromide.5 In our case, neutrophilic activity might have led to the development of needle reaction and dermal neutrophil infiltration. Treatment for bromoderma is discontinuation of the offending agent and the administration of corticosteroids, sodium chloride or ammonium chloride.1,2 For the inhibition of neutrophilic activation, we decided upon potassium iodide because our patient did not want to take an oral steroid. In conclusion, we need to recognize characteristic eruptions in our case as the sign of exposure to bromides including bromocriptine.
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Figure 1. (a) Painful erythema with necrotic ulcer on the left of the abdomen. (b,c) Histopathological findings showed ulcer and dense inflammatory infiltration in the dermis. The inflammatory cells were composed mostly of neutrophils, and some eosinophils, histiocytic and lymphocytes (hematoxylin–eosin, original magnifications: [b] 9100; [c] 9400).
Correspondence: Ikko Kajihara, M.D., Ph.D., Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto-shi, Kumamoto 860-8556, Japan. Email:
[email protected]
© 2016 Japanese Dermatological Association
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Letter to the Editor
CONFLICT OF INTEREST:
None declared.
Saki MAEDA, Ikko KAJIHARA, Aki OGATA, Takamitsu JOHNO, Masatoshi JINNIN, Hironobu IHN Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan doi: 10.1111/1346-8138.13683
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REFERENCES 1 Jih DM, Khanna V, Somach SC. Bromoderma after excessive ingestion of Ruby Red Squirt. N Engl J Med 2003; 348: 1932–1934. 2 Smith SZ, Scheen SR. Bromoderma. Arch Dermatol 1978; 114: 458– 459. 3 Oda F, Tohyama M, Murakami A et al. Bromoderma mimicking pyoderma gangrenosum caused by commercial sedatives. J Dermatol 2016; 43: 564–566. 4 Hafiji J, Majmudar V, Mathews S et al. A case of bromoderma and bromism. Br J Dermatol 2008; 158: 427–429. €bner K, Christophers E, Helmer R. Skin bromide content and bro5 Hu mide excretion in bromoderma tuberosum. Arch Dermatol Res 1976; 257: 109–112.
© 2016 Japanese Dermatological Association
