High incidence of chemotherapy-induced acral erythema in female patients with non-Hodgkin's lymphoma treated with the VACOP-B regimen

Cutaneous toxicity of oral low-dose methotrexate

Chemotherapy-induced acral erythema has been a known side effect of intravenous dosing but has not been reported with oral therapy. Herein we describe two patients receiving treatment with low-dose oral methotrexate who presented with acral erythema. Clinicians and rheumatologists should be aware of this potentially serious side effect of oral chemotherapy in various patient populations. This complication related to methotrexate, though rare, should be anticipated in patients on multiple medications who develop mucocutaneous toxicities.

A Case of Bleomycin-Induced Acral Erythema (AE) with Eccrine Squamous Syringometaplasia (ESS) and Summary of Reports of AE with ESS in the Literature

Chemotherapy-induced acral erythema (AE) is primarily induced by hydroxyurea, methotrexate, and cytarabine, although there are rare reports of AE induced by combination chemotherapy containing bleomycin. It is thought that the accumulation of chemotherapeutic drugs in eccrine glands may cause eccrine squamous syringometaplasia (ESS), which is characterized by metaplasia and focal necrosis of the epithelium of the eccrine duct. ESS is occasionally detected in conjunction with AE, but such occurrences are relatively uncommon. This is the first report of AE with ESS induced by the administration of bleomycin alone. We also provide a summary of past cases of AE with ESS in the literature.

Acral erythema with oral methotrexate in a child

Acral erythema is a rare cutaneous reaction that has been associated with various chemotherapy regimens. Most occurrences have been described in adult patients. Recently, methotrexate has been implicated in the development of acral erythema; however, pediatric reports are few. All of the reports in the pediatric and adult literature have described patients receiving moderate to high-dose intravenous methotrexate. Here, we describe an instance of standard-dose oral methotrexate-associated acral erythema in a young girl with acute lymphoblastic leukemia, and review the recent literature as it relates to pediatric patients.

Vascular Toxicity of Antineoplastic Agents

Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.

Methotrexate-induced bullous acral erythema in a child

Chemotherapy induced acral erythema (CIAE) is an uncommon and dramatic reaction to high-dose chemotherapy. It is characterized by symmetrical, well-demarcated, painful erythema of the palms and soles which may progress to bullae formation and desquamation. Prompt recognition and discrimination from more serious conditions such as graft-vs-host disease or toxic epidermal necrolysis is essential. This paper describes the case of a 12-year-old boy who developed CIAE after high-dose methotrexate treatment and discusses the important clinical, histopathological, and therapeutic features of this condition.

Acral erythema caused by high-dose methotrexate therapy in patients with osteogenic sarcoma

High doses of methotrexate (MTX) have been incorporated in the treatment of osteogenic sarcoma since the 1970s. Unfortunately, high-dose MTX (HD-MTX) can cause untoward side effects that may complicate the proper management of these patients. Two cases of MTX-induced acral erythema are described and the possible implications of this complication are reviewed, with a discussion of the pathophysiology of this adverse effect. Two young female patients suffering from osteogenic sarcoma received HD-MTX (12 g/m2) according to the chemotherapeutic protocol. A 17-year-old patient with osteogenic sarcoma of the head developed painful acral erythema of her palms and soles after the fifth dose of MTX, and a 22-year-old patient with osteosarcoma of the femur developed severe acral erythema after the sixth dose. The severity of the reaction was significant enough to cancel further treatment with HD-MTX in both patients. All symptoms resolved without sequellae several weeks later in both cases. Acral erythema may pose a significant albeit transient phenomenon adversely influencing chemotherapy in patients suffering from osteosarcoma and treated with HD-MTX. The pathophysiology of this side effect is not completely understood and further investigation of the pharmacokinetics of HD-MTX in this patient population is needed.