A 34-year-old male diagnosed with Hodgkin’s lymphoma on ABVD chemotherapy (it includes the drugs doxorubicin hydrochloride [adriamycin], bleomycin sulfate, vinblastine sulfate, and dacarbazine) presented with pruritic skin lesions – which changed color from reddish to dark hyperpigmented ones over 10 days – not responding to topical steroids or antihistamines [Figure 1]. The second course presented with worse reactions, which got better after cold packing over the rashes before chemotherapy.

| Fig. 1 Skin lesions look like below – which are predominantly over the trunk – sparing the limbs and face having whip lash appearance

What is the Diagnosis?

Answer

Bleomycin-induced flagellate erythema.

This is a rare condition where a typical “whip lash” appearance is seen (classic rash with intermingled lacy appearance). One of the postulated mechanisms is lack of bleomycin-hydrolase, making the skin a vulnerable site for the same. Other mechanisms may include localized increase in melanogenesis, pigmentary incontinence secondary to inflammation, alterations in normal pigmentation patterns besides the bleomycin itself. Symptomatic care in the form of antihistamines and topical steroids suffices in cases where the rash does not resolve spontaneously. Heat in an area previously affected by flagellate erythema has caused recurrence, called heat-induced recall. Therefore, cooling before chemotherapy administration might prevent it. Severe rash requires discontinuation of bleomycin.[1]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflict of Interest

There are no conflicts of interest.

• Reference

• 1 Changal KH, Raina H, Changal QH, Raina M. Bleomycin-induced flagellate erythema: A rare and unique drug rash. West Indian Med J 2014; 63: 807-9

Address for correspondence

Publication History

Received: 24 December 2019
Accepted: 06 January 2020
Article published online:
03 June 2021

© 2020. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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| Fig. 1 Skin lesions look like below – which are predominantly over the trunk – sparing the limbs and face having whip lash appearance

• Reference

• 1 Changal KH, Raina H, Changal QH, Raina M. Bleomycin-induced flagellate erythema: A rare and unique drug rash. West Indian Med J 2014; 63: 807-9