Journal of Dermatological Treatment. 2009; 20:374–375
LETTER
J Dermatolog Treat Downloaded from informahealthcare.com by D S Diffusioni Scientifiche - Unical on 11/18/13 For personal use only.
Successful treatment of pyogenic granulomas following gefitinib therapy with partial matricectomy and phenolization EMI DIKA, RICCARDO BALESTRI, SABINA VACCARI, PIER ALESSANDRO FANTI, COSIMO MISCIALI, ANNALISA PATRIZI Internal Medicine, Aging and Nephrologic Diseases Department, Dermatology Division, Università degli Studi di Bologna, Bologna, Italy
Sirs, A 72-year-old woman was referred to us because of the occurrence of painful toenail lesions, which had been present for 1 month. The patient had been on gefitinib (Iressa®, AstraZeneca Pharmaceuticals LP, Wilmington, DE, USA) therapy for 13 months for the treatment of lung metastatic neoplasia. Clinical examination revealed mild paronychia and three erythematous nodules surrounding the lateral nail fold of both toenails (Figure 1). Patient history revealed folliculitis on the lower limbs and a papular eruption on the upper chest and back at the beginning of treatment with this drug (fourth and sixth months of therapy). Both of these inflammations were successfully treated by her oncologist with topical antibiotics (erythromycin 3% cream). She denied exposure to microtraumas. No other drugs had been prescribed by her physician or oncologist. Pyogenic granulomas, Kaposi’s sarcoma, angiosarcoma and metastasis from her cancer were considered on differential diagnosis. Biopsy of one of the nodules was performed and histologic examination showed angiomatous tissue composed of a variable dilated network of blood-filled capillary vessels embedded in an edematous stroma containing inflammatory neutrophylic infiltrate (Figure 2). A diagnosis of pyogenic granuloma was performed on the basis of clinical and histological presentation. Topical therapy with corticosteroids and antibiotics (clobetasol propionate cream 0.05% and mupirocine ointment) was prescribed for a 2-week period, with a reduction of the symptomatology related to paronychia but persistence of pyogenic granulomas. Therapy with gefitinib was not interrupted.
Partial matricectomy and phenolization was performed on both toenails, leading to healing of the lesions (Figure 3). Gefitinib and other drugs that block epidermal growth factor receptor have been associated with a large and interesting pattern of cutaneous adverse effects, including acneiform eruptions, xerosis, desquamation, seborrheic dermatitis, chronic paronychia, and hair texture changes (1,2). Another case of pyogenic granuloma associated with this drug has been described (3). The mechanism underlying these cutaneous manifestations is yet to be determined. Pyogenic granuloma is a common, acquired, benign vascular lesion of the skin and mucous membranes, which may occasionally present intravascularly or subcutaneously. Drug-induced pyogenic granulomas have often been reported, especially after chemotherapy, systemic retinoids and antiretroviral agents (4,5). The aim of this letter is to underline that pyogenic granulomas may occur during treatment with gefitinib and though the related discomfort may compromise compliance, no discontinuation of chemotherapy is needed. Literature data report recurrence and a scarce control of these kinds of lesions after surgical therapy but amelioration on gefitinib discontinuation (6). To our knowledge, there are no cases of pyogenic granulomas treated with partial matricectomy and phenolization. No recurrence of the pyogenic granulomas or paronychia was observed in our patient at a 12-month follow-up, and hence treatment with gefitinib was continued.
Correspondence: Emi Dika, V. Massarenti 1, 40138 Bologna, Italy. E-mail:
[email protected] (Recevied 16 January 2009; accepted 20 January 2009) ISSN 0954-6634 print/ISSN 1471-1753 online © 2009 Informa UK Ltd. DOI: 10.3109/09546630902773502
Pyogenic granulomas following gefitinib therapy
375
J Dermatolog Treat Downloaded from informahealthcare.com by D S Diffusioni Scientifiche - Unical on 11/18/13 For personal use only.
References
Figure 1. Pyogenic granulomas of both toenails following gefitinib therapy.
Figure 2. Histologic examination showing angiomatous tissue composed of a variable dilated network of blood-filled capillary vessels embedded in an edematous stroma containing inflammatory neutrophylic infiltrate. (H&E 10 × low power.)
Figure 3. At 10 days after partial matricectomy and phenolization of both thumbs.
1. Guhl G, Gonzales-de Arriba A, Dauden E. Epidermal growth factor receptor inhibitors side effects. Actas Dermosifiliogr. 2006;97:296–310. 2. Graves JE, Jones BF, Lind AC, Heffernan MP. Nonscarring inflammatory alopecia associated with the epidermal growth factor receptor inhibitor gefitinib. J Am Acad Dermatol. 2006;55:349–53. 3. High WA. Gefitinib: A case of pyogenic granuloma-like lesions of the nail. Arch Dermatol. 2006;142:939. 4. Piraccini BM, Iorizzo M, Starace M, Tosti A. Drug-induced nail disease. Dermatol Clin. 2006;24:387–91. 5. Frantz S. Drug discovery: Playing dirty. Nature. 2005;437:942–3. 6. Segaert S, Van Cutsem E. Clinical signs, pathophysiology and management of skin toxicity during therapy with epidermal growth factor receptor inhibitors. Ann Oncol. 2005;16:1425–33.
