Affiliations of authors: C. Belda-Iniesta, E. Casado, B. Castelo, M. González Barón (Medical Oncology División), M. Corral de la Calle (Dermatology División), Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain.
Correspondence to: Manuel Gonzalez-Baron, M.D., Ph.D., Servicio de Oncología Médica, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain (e-mail: mgonzalezb.hulp{at}salud.madrid.org).
Chemotherapy can cause different cutaneous toxicities usually masked by the underlying life-threatening malignancy or treatment-associated complications. Here we describe the first two known cases of paclitaxel-related folliculitis. The first case occurred in a 55-year-old white male with 5-fluorouracil (5-FU)/cisplatin refractory disseminated epidermoid esophageal cancer, who received weekly paclitaxel (150 mg/m2 on days 1, 8, 15, and 22 every 6 weeks), with partial response. After two cycles of this regimen, the patient developed pruriginous cutaneous lesions. The lesions on the patients face and upper chest consisted of multiple follicular erythematous papules and pustules. Bacterial cultures of pustules were negative, and a biopsy of one of the lesions showed a neutrophilic infiltration without eosinophilic cells. The patient was diagnosed with acute folliculitis. Paclitaxel dose reduction was unsuccessful in reversing this cutaneous toxicity; thus, paclitaxel treatment was suspended.
The second case of folliculitis occurred in a 59-year-old white male with locally advanced epidermoid esophageal cancer, who was treated with the aforementioned weekly paclitaxel schedule. After receiving two doses of paclitaxel, the patient developed follicular papules and pustules on the forehead, cheeks, chin, and upper chest; bacterial cultures obtained from pustules were negative. This toxicity was ameliorated at days 3540 in the treatment cycle but worsened when chemotherapy was reintroduced. The patient was diagnosed with acute folliculitis in response to weekly paclitaxel. Because this toxicity was mild, paclitaxel was not suspended.
Antineoplastic drugs have been reported to cause a variety of skin toxicities. For example, taxane use is associated with onycholysis (1). Paclitaxel infrequently produces dermatologic reactions, mainly pustular dermatosis (2) and fixed drug eruption (3).
Rarely, folliculitis has been associated with paraneoplastic syndromes, but never in the context of cancer of the esophagus (4); it has also been associated with HIV infections and POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy or edema, M-protein, and skin changes), neither of which were diagnosed in the two patients described here.
Methylprednisolone, used as a premedication to avoid allergic reactions to paclitaxel, was the only drug taken by both of the patients described here that has previously been associated with folliculitis. Cutaneous toxicity in response to steroid use usually presents as small papules and pustules that evolve morphologically identically over time. In the two cases described here, the pustules were in different stages and had not previously developed when steroids were given for antiemetic premedication of first-line therapies. Hematopoietic factors that can cause folliculitis were not used in our patients (5). Finally, 5-FU is unlikely to cause delayed cutaneous toxicity (6).
Hence, the differential diagnoses and the improvement of cutaneous lesions after paclitaxel use was suspended suggest that weekly treatment with paclitaxel was directly associated with the development of folliculitis in these two patients. To our knowledge, these are the first two cases of paclitaxel-induced folliculitis.
Chemotherapy-induced folliculitis has recently emerged as a subject of great interest because it is a common side effect of epidermal growth factor receptor (EGFR)-targeted therapies (7). We recommend that the potential for paclitaxel-associated folliculitis be considered in all combination chemotherapy regimens that involve taxanes, especially to preclude erroneous associations of folliculitis with EGFR-targeted therapies.
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