Hydroxyurea-induced dermatomyositis-like eruption

Investigating the disparities among drug categories in drug-induced dermatomyositis: A systematic review

Drug-induced dermatomyositis (DIDM) is a rare and underestimated variant of dermatomyositis (DM) characterized by muscle damage and skin rash and related to certain drug exposure. The spectrum of drugs causing DIDM has evolved over time, originally implicating hydroxyurea, penicillamine, and statins as causative agents. Tumor necrosis factor α inhibitors and immune checkpoint inhibitors have also been associated with such conditions. To bridge the gap between current literature and clinical practice, and therefore guide clinicians, we conducted a comprehensive review of English literature from Pubmed, EMBASE, and MEDLINE. Our analysis included demographic data, clinical features, laboratory findings, therapeutic outcomes, and extant research pertaining to the probable pathogenesis of DIDM induced by various drugs. Furthermore, we categorized the drugs involved in DIDM cases into biologics and traditional agents for subsequent statistical analysis. Over time, there has been a gradual accumulation of reported DIDM cases. A total of 69 published DIDM cases were documented in our study, among which 33 should be attributed to biologics and the remaining 36 to traditional drugs. Interestingly, 41 of all DIDM cases had a previous history of malignancies. Additionally, DIDM cases exhibited similar cutaneous and muscular manifestations to classic DM, with the exception of cases induced by hydroxyurea, which did not entail muscle damage. Positive antinuclear antibodies and anti-TIF1-γ autoantibodies have been predominantly observed in biologics-induced cases, while positive anti-TIF1-γ antibodies were merely reported in the cases that were primarily diagnosed with malignant diseases and exposed to ICIs afterwards. Anti-TIF1-γ antibodies may potentially serve as a red flag in the identification of co-existing malignant diseases in DM patients. We also provided a comprehensive summary and exploration of potential mechanisms lying behind drug-induced dermatomyositis. In conclusion, our review consolidates the current literature on DIDM, highlighting the evolving spectrum of medications and elucidating the differences in clinical manifestations, laboratory findings, and underlying mechanisms.

Environmental triggers of dermatomyositis: a narrative review

Dermatomyositis (DM) is an autoimmune disease that affects the skin, lungs, and muscle. Although the pathogenesis of DM is not completely understood, several environmental triggers have been linked to DM onset or flare. This article specifically examines the effects of herbal supplements, drugs, infections, ultraviolet (UV) radiation, and environmental pollutants on the onset or exacerbation of DM. Herbal supplements such as Spirulina platensis, Aphanizomenon flos-aquae, Chlorella, Echinacea, and Alfalfa have been implicated and are frequently used in health foods. Medications such as hydroxyurea, TNF-α inhibitors, immune checkpoint inhibitors (ICI), and penicillamine, as well as certain viral infections, such as parvovirus B19, coxsackie virus, polyomavirus, Epstein-Barr virus (EBV), hepatitis, influenza, and human immunodeficiency viruses (HIV) have been associated with DM onset. Bacterial infections and vaccinations have also been linked to the development of DM. Additional environmental factors, including UV radiation and air pollutants, such as silica, biological/mineral dust, and particulate air matter from vehicle and industrial emissions, may also play a role in DM pathogenesis. Overall, there is general agreement that an autoimmune attack of the skin, muscle, and lungs in DM can be triggered by various environmental factors and warrants further investigation.

Hydroxyurea: a reappraisal of its cutaneous side effects and their management

Hydroxyurea (HU) is known to cause a broad spectrum of cutaneous side effects, ranging from relatively benign to severe. Although dermatologists are often consulted for the treatment of these side effects, a comprehensive resource discussing the different types and their management is lacking. In this study, we conducted a literature search in order to critically evaluate the reported types and management of hydroxyurea's cutaneous side effects, as well as review its mechanism of action, dermatologic uses, and common systemic side effects. Relatively common and benign side effects include hyperpigmentation, xerosis, and skin atrophy. While serious cutaneous side effects such as leg ulcers or nonmelanoma skin cancers occur in a substantial proportion of patients, these may resolve with HU discontinuation and proper dermatologic management. Therefore, it is crucial for dermatologists to be aware of these various cutaneous side effects and their management as prompt diagnosis and proper treatment will improve patient outcomes.

Drug-Related Cutaneous Adverse Events in Philadelphia Chromosome-Negative Myeloproliferative Neoplasms: A Literature Review

Since myeloproliferative neoplasms (MPN) pose a significant risk for vascular and thrombotic complications, cytoreductive therapies, such as hydroxyurea (HU), interferon (IFN) inhibitors, and Janus kinase (JAK) inhibitors are recommended for patients at high risk. However, these agents also place patients at increased risk for drug-related cutaneous adverse events. Herein, we review the literature on skin toxicity related to the use of drugs for the treatment of MPN. Overall, the cytoreductive agents used for MPN are generally well tolerated and considered to be safe, except IFN, for which dropout rates as high as 25% have been reported. While IFN is known to give rise to flu syndrome, it rarely leads to hematological alterations. The most common hematological side effects of HU are mild and include granulocytopenia, anemia, and thrombocytopenia. The JAK inhibitor ruxolitinib has been associated with cytopenia and a higher incidence of viral infections, as well as increased risk for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Based on the present analysis, it can be concluded that cutaneous toxicity is not a negligible complication of commonly used treatments for MPN. While further research is needed, patients on these agents, and especially those with a history of cutaneous malignancies, should undergo thorough skin examination before and during therapy. In addition, detailed history is critical since many patients who develop non-melanoma skin cancer have multiple preexisting risk factors for cutaneous carcinogenesis.

Essential Thrombocythemia: The Dermatologic Point of View

Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by an increase in blood platelets and dominated by a predisposition to vascular events. Cutaneous manifestations can complicate its course. itching has been the most common symptom reported; however, the percentage has ranged from 3% to 46%, depending on the survey. Erythromelalgia is found in 6% of cases, and livedo reticularis, minor bleeding, acrocyanosis, and Raynaud's phenomenon are rare manifestations. It is important to recognize and treat these events, because they can affect patients' quality of life and could worsen the prognosis. In addition to skin involvement as a possible sign of ET, the treatment of ET can be associated with cutaneous complications. Hydroxycarbamide, interferon-alfa, and anagrelide can induce different skin lesions. Hydroxycarbamide has been associated with major complications, including painful leg ulcers and actinic keratoses. Minor events include alopecia and hyperpigmentation. Xerosis, pruritus, and photosensitivity are some of the complications reported by patients treated with interferon-alfa. Anagrelide has proved to be associated with fewer dermatologic effects, only detected in single cases. Knowledge of the ET cutaneous manifestations, together with the clinical examination findings, can result in an earlier diagnosis and the start of effective treatment.

Hydroxyurea-induced dermatomyositis: true amyopathic dermatomyositis or dermatomyositis-like eruption?

BACKGROUND

  Hydroxyurea-induced dermatomyositis is a rare adverse reaction of long-term hydroxyurea therapy. It has been reported under different names; however, the exact classification and nomenclature of this eruption have been the subject of much debate, and a more precise term is still awaiting. Herein, we review the different aspects of this reaction and suggest a new term that might help to minimize the confusion about its nomenclature.

MATERIALS AND METHODS

We describe a 68-year-old woman who had been on long-term hydroxyurea therapy for the treatment of chronic myeloid leukemia for nine years. She presented with typical dermatomyositis-like lesions and many of the other mucocutaneous adverse effects of hydroxyurea.

RESULTS

Skin examination revealed typical Gottron's papules on the dorsa of the hands, atrophy, xerosis, acquired ichthyosis, photosensitivity, cutaneous, oral and nail hyperpigmentation, acral erythema, palmoplantar keratoderma, actinic keratoses, and leg ulcers. There was no clinical or laboratory evidence of proximal muscle weakness. Cessation of hydroxyurea was associated with remarkable improvement of the skin lesions.

CONCLUSION

Hydroxyurea-induced dermatomyositis is a rare drug-induced dermatomyositis characterized by skin lesions identical to classic dermatomyositis without clinical or laboratory evidence of myositis. We propose that the term hydroxyurea-induced amyopathic dermatomyositis that adequately describes the findings reported in this subset of patients would be more precise and specific.

[Ulcers following therapy with hydroxyurea. Three case reports and review of the literature]

Hydroxyurea is frequently used for therapy of myeloproliferative disorders. One cutaneous side-effect is painful, therapy-resistant ulcers which have bizarre configurations and occur at atypical sites for venous ulcers. Improvement or healing often first occurs when hydroxyurea is discontinued. We report on one patient with essential thrombocythemia and two with polycythemia vera, who developed such ulcers during hydroxyurea therapy. In one case, the ulcers developed shortly after hydroxyurea was started. In addition we give a short overview of the current literature.

Dermatomyositis induced by drug therapy: a review of case reports

BACKGROUND

Drugs have occasionally been implicated in dermatomyositis (DM) onset.

OBJECTIVE

We sought to review case reports of drug-induced DM.

METHODS

Articles were gathered from MEDLINE and bibliographies of acquired reports. Causality was assessed using World Health Organization criteria. Clinical characteristics, management, and resolution were examined.

RESULTS

In 70 reported cases, 50% of patients were female and the median age was 57 years. Hydroxyurea was implicated in 51% of cases. All cases had pathognomonic (76%) or compatible (24%) cutaneous findings. Hydroxyurea cases lacked myositis, but myositis was described in 79.4% of nonhydroxyurea cases. Drug causality was probable (25.7%) or possible (74.3%), but not certain in any case. Most patients had underlying pathology associated with DM (44% had malignancy; 16% had rheumatoid arthritis). Of the sample, 84.3% had improvement of DM after discontinuation of the drug.

LIMITATIONS

Case reports may emphasize unusual findings.

CONCLUSIONS

Further work is needed to differentiate drug effects from underlying, predisposing factors.

Cutaneous reactions to chemotherapy and their management

International data from 2002 report 10.9 million new cases of cancer and 6.7 million cancer deaths. Chemotherapy is an essential component in the multidisciplinary management of most cancers. Cutaneous reactions to chemotherapeutics are common and may contribute significantly to the morbidity, and rarely to the mortality, of patients undergoing such treatments. Recognition and management of these reactions is important to provide optimal care. This article aims to present the most common cutaneous reactions to frequently used chemotherapies and provides management guidelines. A MEDLINE search from 1966 through June 2005 was conducted to identify reports of common cutaneous toxicities with systemic chemotherapy and their appropriate management. An analysis of our literature search is presented in review form outlining common chemotherapy-related cutaneous reactions and their management, as well as the chemotherapeutics responsible for the cutaneous toxicity. Chemotherapy-related cutaneous toxicity includes generalized rashes such as the spectrum between erythema multiforme and toxic epidermal necrolysis, and site-specific toxicity such as mucositis, alopecia, nail changes, extravasation reactions, or hand-foot syndrome. Most of the toxicity is reversible with chemotherapy dose reductions or delays. Certain toxicities can be effectively treated or prevented, allowing optimal delivery of chemotherapy (e.g. premedications to prevent hypersensitivity, prophylactic mouthwashes to prevent mucositis). Newer non-chemotherapeutic targeted therapies such as epidermal growth factor receptor inhibitors (e.g. gefitinib, cetuximab) may also be associated with cutaneous toxicity and can be distressing for patients. Recent data suggest that skin toxicity associated with these agents may correlate with efficacy. Cutaneous toxicity occurs frequently with chemotherapy and non-chemotherapeutic biologic therapies. Early recognition and treatment of the toxicity facilitates good symptom control, prevents treatment-related morbidity, and allows continuation of anti-cancer therapy.

Mucocutaneous side effects of antineoplastic chemotherapy

All structures of the skin may be affected by side effects of antineoplastic chemotherapy. The most commonly described effects concern skin adnexes, especially hair with alopecia. Nails are also frequently involved. Eccrine sweat or sebaceous gland involvement is more rarely reported. Mucous membranes, particularly in the mouth, are frequently altered by several mechanisms; direct cytotoxicity, infection, and a decrease in polymorphonuclear or platelet counts. Among cutaneous side effects, hyperpigmentation is very common and may have different clinical patterns; generalised, figurated, or localised. Acral erythema is another cutaneous side effect that is relatively specific to chemotherapy and is often dose-related. Some cutaneous side effects are related to an interaction between chemotherapy and radiation, particularly phototoxicity, recall phenomenon, and radiation enhancement. Miscellaneous, less frequent, side effects are described; sclerodermiform dermatitis, Raynaud's phenomenon, and hypersensitivity syndrome. In some cases, cutaneous side effects are relatively specific to one type of drug. Capillary leak syndrome is most often related to taxanes. Hydroxyurea is responsible for some peculiar cutaneous side effects (ulcerations, pseudo-dermatomyositis), perhaps due to long-term administration of the drug. Although mucocutaneous side effects of chemotherapy are frequent and sometimes severe, interruption of the culprit drug is rarely mandatory. However, adaptation of the dosage or prevention of some of these side effects remains necessary. Antineoplastic chemotherapies are widely used in many therapeutic protocols and may be responsible for numerous mucocutaneous side effects, either specific or more unusual. In rare cases, the severity of these side effects may require interruption of therapy. They may involve skin adnexes, mucous membranes or the skin itself. This review discusses cytotoxic antineoplastic drugs only, not cytokines, monoclonal antibodies or transduction factors used in the treatment of cancer.

Hydroxyurea-induced melanonychia concomitant with a dermatomyositis-like eruption

We describe the cases of 7 patients with hydroxyurea-induced melanonychia. In two of the patients, a dermatomyositis-like eruption was also present.

Hydroxyurea-induced dermatomyositis-like eruption

Hydroxyurea is a cytotoxic chemotherapeutic agent used for myelodysplasia. The adverse cutaneous effects due to hydroxyurea include leg ulcers, hyperpigmentation of the skin and nails, a lichen planus-like eruption, lupus erythematosus, and a dermatomyositis-like eruption. We present a case of hydroxyurea-induced dermatomyositis-like eruption and review the features of this entity as previously reported.

Cutaneous Reactions to Chemotherapeutic Agents

The task of evaluating a cutaneous eruption in the patient receiving chemotherapy can be quite formidable. Most of the time, these patients are receiving a multitude of agents and have profound immunosuppression. These factors may alter the more common manifestations of cutaneous eruptions. This article presents some of the more common cutaneous eruptions that may occur in an oncology patient receiving chemotherapy. It is hoped we may recognize clinical patterns seen with chemotherapeutic agents in the immunosuppressed population and, by recognizing these cutaneous eruptions, we may avoid the pitfalls of discontinuing medicines that may certainly be needed or altering the treatment course in a patient.

Dermatomyositis

Dermatomyositis is a disease that has a characteristic skin eruption that may occur with or without a proximal myopathy. The disease with cutaneous features only is classified as amyopathic dermatomyositis. The origin is unknown, but autoimmune factors are believed to play an important role. Autoantibodies are found in most patients and some have myositis-specific antibodies. Systemic changes may occur and there appears to be a relationship to internal malignancy, particularly in older patients. Juvenile disease has an associated vasculopathy. Treatment includes systemic corticosteroids and other immunosuppressive agents. The cutaneous changes may be difficult to treat.

Muco-cutaneous changes during long-term therapy with hydroxyurea in chronic myeloid leukaemia

Hydroxyurea is an antimetabolite agent used in the treatment of myeloproliferative disorders and sickle cell anaemia. Although hydroxyurea is relatively well tolerated, adverse effects often involve skin and mucous membrane during long-term therapy. A group of 510 patients affected by chronic myeloid leukaemia from 1977 to 1998 has been considered. Only 158 patients were treated with hydroxyurea and fulfilled inclusion/exclusion criteria of this study. A spectrum of severe cutaneous and mucosal changes (inflammatory and neoplastic) was seen in about 13% of patients (21 patients out of 158) and was studied in detail. Cutaneous and mucosal atrophy were observed in all 21 patients. Skin atrophy was often characterized by numerous telangiectases, especially on legs and on sun-exposed sites (16/21). Cutaneous, mucosal and nail hyperpigmentation was evident, albeit with variable extent, in 10 of the 21 patients. Severe stomatitis and glossitis with flattening of papillae were another common finding. Five patients, who received a particularly long treatment with hydroxyurea, developed squamous-cell neoplasms on sun-exposed sites (both squamous-cell carcinomas and keratoacanthomas). Acral changes were characteristic and constant, including acral erythema (21/21), dermatomyositis-like changes on the dorsa of hands (7/21), ulcers localized on acral areas of legs, on genitalia and oral mucosae (20/21). The frequency and the variety of these muco-cutaneous changes are reported and the mechanisms by which hydroxyurea may induce this muco-cutaneous syndrome-like group of changes, are proposed.

The cutaneous side-effects of hydroxyurea

The cutaneous side-effects of long-term hydroxyurea therapy are not widely known and only rarely reported. We report on a patient who developed widespread skin changes, including the recently recognized hydroxyurea dermopathy, during long-term treatment with hydroxyurea for polycythaemia rubra vera. The time course of the clinical changes suggests that they result from direct toxicity of hydroxyurea on the basal layer of the epidermis and mucosal surfaces. We aim to increase clinical awareness of this problem.

[Secondary cutaneous effects of hydroxyurea: prospective study of 26 patients from a dermatologic consultation]

PURPOSE

Hydroxyurea is a treatment of myeloproliferative syndromes. Its cutaneous side-effects are underestimated, because they are usually benign. We undertook a prospective study to evaluate their frequency.

METHODS

During a 2-year period, all patients taking hydroxyurea for more than 6 months who had consultations at the dermatology department were systematically examined, regarding cutaneous side effects.

RESULTS

Twenty-six patients were examined. All but one had cutaneous side-effects, including dryness (n = 16), moderate alopecia (n = 2), increased skin pigmentation (n = 5), melanonychia, single (n = 1) or multiple (n = 7), cutaneous atrophy (n = 4), leg ulcers (n = 8), plantar keratoderma (n = 3), pseudodermatomyositis (n = 1), lichen planus-like eruption on the dorsum of the hands (n = 2), actinic keratosis (n = 8), squamous cell carcinomas (n = 2), and mouth ulcerations (n = 1).

CONCLUSION

This study shows that the frequency of hydroxyurea cutaneous side-effects diagnosed in 95% of studied patients is underestimated. They are usually benign, but some of them, in particular leg ulcers and squamous cell carcinomas, lead to modification of the treatment (39% of studied patients).

Dermatomyositis-like eruption and leg ulceration caused by hydroxyurea in a patient with psoriasis

We report the case of an elderly woman who had been on hydroxyurea for long-standing widespread psoriasis. After approximately 5 years's treatment with hydroxyurea, she developed a symmetrical dermatomyositis-like eruption on her hands, together with bilateral leg ulceration. Although similar skin eruptions have been reported after long-term hydroxyurea treatment, all of the previous patients were being treated for myeloproliferative disorders. A dermatomyositis-like eruption has not previously been reported to occur as a consequence of hydroxyurea treatment for psoriasis. Its recognition is important to prevent unnecessary investigation or treatment withdrawal.

Mucocutaneous reactions to chemotherapy

Chemotherapeutic agents are a widely used treatment modality. Side effects range from common to unusual and may be confused with other cutaneous sequelae of oncologic treatment. The goal of this communication is to elaborate on previous descriptions of the cutaneous manifestations of chemotherapeutic treatment and to discuss more recent findings.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be able to generate a differential diagnosis of possible etiologies for varying patterns of cutaneous involvement in patients receiving chemotherapy and identify the various cutaneous side effects of chemotherapeutic treatment. In addition, they should be able to distinguish life-threatening side effects that require immediate management from more benign manifestations of chemotherapeutic treatment.

Early cutaneous lesions secondary to hydroxyurea therapy

Hydroxyurea is a usually well-tolerated cytostatic agent, but its side effects include cutaneous lesions that appear after several years of maintenance therapy with hydroxyurea. The reported incidence of such adverse reactions varies from 10 to 35%; in our Center it is 2%. We describe a patient with essential thrombocythemia who presented with ulcers of the hands only 15 days after hydroxyurea treatment.