Spiny follicular hyperkeratosis eruption: a new cutaneous adverse effect of sorafenib

s-HBEGF/SIRT1 circuit-dictated crosstalk between vascular endothelial cells and keratinocytes mediates sorafenib-induced hand-foot skin reaction that can be reversed by nicotinamide

Hand-foot skin reaction (HFSR), among the most significant adverse effects of sorafenib, has been limiting the clinical benefits of this frontline drug in treating various malignant tumors. The mechanism underlying such toxicity remains poorly understood, hence the absence of effective intervention strategies. In the present study, we show that vascular endothelial cells are the primary cellular target of sorafenib-induced HFSR wherein soluble heparin-binding epidermal growth factor (s-HBEGF) mediates the crosstalk between vascular endothelial cells and keratinocytes. Mechanistically, s-HBEGF released from vascular endothelial cells activates the epidermal growth factor receptor (EGFR) on keratinocytes and promotes the phosphorylation of c-Jun N-terminal kinase 2 (JNK2), which stabilizes sirtuin 1 (SIRT1), an essential keratinization inducer, and ultimately gives rise to HFSR. The administration of s-HBEGF in vivo could sufficiently induce hyper-keratinization without sorafenib treatment. Furthermore, we report that HBEGF neutralization antibody, Sirt1 knockdown, and a classic SIRT1 inhibitor nicotinamide could all significantly reduce the sorafenib-induced HFSR in the mouse model. It is noteworthy that nicotinic acid, a prodrug of nicotinamide, could substantially reverse the sorafenib-induced HFSR in ten patients in a preliminary clinical study. Collectively, our findings reveal the mechanism of vascular endothelial cell-promoted keratinization in keratinocytes and provide a potentially promising therapeutic strategy for the treatment of sorafenib-induced HFSR.

A Case Report of Idiopathic Follicular Hyperkeratotic Spicules and Literature Review

Follicular hyperkeratotic spicules is a rare skin disorder that is usually associated with multiple myeloma. The condition typically presents with tiny hyperkeratotic spicules in follicular distribution and predominantly on the face. To our knowledge, there has been one reported case of this condition without underlying disease. We herein report the second case of idiopathic follicular hyperkeratotic spicules in a 54-year-old Thai woman presenting with multiple follicular horn-like spicules on her face and neck.

Acitretin-induced spiny follicular hyperkeratosis

Spiny follicular hyperkeratosis (SFH) is follicular flesh-colored hyperkeratotic spicules that are linked to different situations including drug reactions. Previously suspected drugs are BRAF inhibitors and cyclosporine. We described a 51-year-old psoriasis patient with SFH who had been using acitretin.

Sorafenib-associated facial acneiform eruption

INTRODUCTION

Sorafenib is an oral multikinase inhibitor that targets tumor cell angiogenesis and proliferation. Drug-associated cutaneous adverse events, such as alopecia and hand-foot skin reaction, occur frequently. Sorafenib-related side effects affecting hair, nails, and skin are summarized and the characteristics of sorafenib-treated patients who developed acneiform facial lesions are reviewed to present the clinical features of these individuals.

CASE REPORT

A man with sorafenib-associated facial acneiform lesions mimicking those of chloracne is described.

DISCUSSION

PubMed was used to search the following terms, separately and in combination: acne, acneiform eruption, chloracne, cutaneous adverse events, hepatocellular carcinoma, renal cell carcinoma, skin side effects, and sorafenib. Inclusion criteria for selecting papers to be reviewed included case reports and studies that described cutaneous and mucosal adverse side effects associated with sorafenib. All papers fulfilling inclusion criteria were reviewed and relevant manuscripts, along with their reference citations, were evaluated. Five patients-a woman with liver epithelioid hemangioendothelioma, three men with metastatic renal cell carcinoma, and a man with hepatocellular carcinoma-have developed sorafenib-associated facial acneiform eruption. The eruption typically occurred after 4 weeks of treatment at a dose of 400 mg twice daily. The lesions presented as either papules and pustules (2 patients) or, similar in appearance and distribution to chloracne, only open and closed comedones (3 patients). The sorafenib-associated facial acneiform eruption partially improved after initiating topical antibiotics, keratolytics, and/or retinoids; however, progressive improvement or resolution occurred after lowering the daily dose or discontinuation of sorafenib.

CONCLUSIONS

Sorafenib-associated facial acneiform eruption is a rarely occurring cutaneous adverse event that has only been observed in five individuals. The skin lesions usually presented after 4 weeks of sorafenib (at a dose of 400 mg twice daily) treatment. The morphology and distribution of the lesions mimicked those of chloracne in three of the patients. Two of the patients also had other drug-related skin side effects. Topical acne-directed therapy was only partially effective in clearing the lesions; lowering the dose or discontinuation of sorafenib resulted in progressive improvement or resolution of the facial acneiform eruption.

Drug safety evaluation of sorafenib for treatment of solid tumors: consequences for the risk assessment and management of cancer patients

INTRODUCTION

Sorafenib is a multi-tyrosine kinase inhibitor (TKI). Considerable clinical experience has been accumulated since its first Phase III clinical trial in metastatic renal cancer patients in 2007. The management of its early acute toxicity in fit patients is well known. The management of prolonged treatment becomes the new challenge.

AREAS COVERED

Using sorafenib as a key word for PubMed search, we review preclinical and clinical data and discuss the pharmacokinetics and pharmacodynamics of sorafenib, its acute and cumulative toxicities and their consequences for patient management.

EXPERT OPINION

The systematic multi-disciplinary risk assessment of cancer patients prior to TKI initiation reduces the risks of acute and late toxicity, especially drug-drug interactions and arterial risks. Sarcopenia is now identified as a major risk of severe toxicity. The very diverse clinical pictures of cumulative toxicity must be known. The monitoring of sorafenib systemic exposure is helpful especially in elderly patients. Moreover, at disease progression, it allows distinguishing between underexposure to sorafenib and truly acquired resistance to the drug. The optimal use of sorafenib should allow improving the reported results of flat-dose. Finally, most of this knowledge could be used for the development and optimal use of the other TKIs.

Adult onset atopic dermatitis with secondary follicular mucinosis with cyclosporine induced spiny follicular hyperkeratosis and hair casts

Secondary follicular mucinosis developing in adult patient with atopic dermatitis (AD) was observed on histology. Due to severity of disease, patient was started on oral cyclosporine 300 mg daily in 3 divided doses. Two weeks later patient started developing multiple spiny follicular keratoses mainly on face but also on extremities and trunk along with hair casts on scalp. Repeat biopsy from such keratotic lesions confirmed diagnosis spiny follicular hyperkeratosis (SFH). On investigations no evidence of multiple myeloma or any other malignancy was found. Cyclosporine was stopped and lesions cleared over 2 weeks. We report this case due to rare association of AD with follicular mucinosis and cyclosporine induced SFH with hair casts.

Variability of sorafenib toxicity and exposure over time: a pharmacokinetic/pharmacodynamic analysis

BACKGROUND

Sorafenib displays major interpatient pharmacokinetic variability. It is unknown whether the pharmacokinetics of sorafenib influence its toxicity.

METHODS

We analyzed the severity and kinetics of sorafenib-induced toxicities in unselected consecutive patients with cancer, as well as their relationship with biological, clinical, and pharmacokinetic parameters. Toxicity was recorded bimonthly. Sorafenib plasma concentrations were assessed by liquid chromatography.

RESULTS

For 83 patients (median age, 62 years; range, 21-84 years), median sorafenib 12-hour area under the curve (AUC(0-12)) was 52.8 mg · h/L (range: 11.8-199.6). A total of 51 patients (61%) experienced grade 3-4 toxicities, including hand-foot skin reactions (23%), asthenia (18%), and diarrhea (11%). Sorafenib AUC(0-12) preceding grade 3-4 toxicities was significantly higher than that observed in the remaining population (61.9 mg · h/L vs. 53 mg · h/L). In 25 patients treated with fixed doses of sorafenib for the first 4 months, median dose-normalized AUC(0-12) on day 120 was significantly lower than on day 15 (63 vs. 102 mg · h/L). The incidence of hypertension and hand-foot skin reactions significantly decreased over time.

CONCLUSION

Sorafenib AUC(0-12) decreases over time, similarly to the incidence of hypertension and hand-foot skin reactions. Monitoring of sorafenib plasma concentrations may help to prevent acute severe toxicities and detect patients with suboptimal exposure at disease progression.

Cutaneous toxicities of the multikinase inhibitors sorafenib and sunitinib

Multikinase inhibitors have become first-line agents for treatment of multiple systemic cancers. These agents are very effective but can also cause a variety of toxicities affecting the skin, hair, and nails. One of the most common reactions is the hand-foot skin reaction, distinct from hand-foot syndrome caused by more traditional chemotherapy agents. All of these cutaneous reactions can negatively affect patients' quality of life and can lead to dose modifications and treatment interruptions. This article reviews the cutaneous toxicities from sorafenib and sunitinib with emphasis on treatment strategies.