Case Report 134 Adress for correspondence: Uzm. Dr. Suna Çokmert Çetin Emeç Mah. Rüstempaşa Sokak No=4 35100 İzmir – Türkiye e-mail: sunacok@gmail.com Available at www.actaoncologicaturcica.com Copyright ©Ankara Onkoloji Hastanesi Flagellate Hyperpigmentation Following Treatment with Low-Dose Bleomycine: Report of two cases Düşük Doz Bleomisin ile Tedaviyi Takiben Flajella Benzeri Hiperpigmentasyon: İki Vaka Raporu Suna Çokmert 1 , Lütfiye Demir 2 , Murat Akyol 3 1 Kent Hastanesi, Tıbbi Onkoloji, İzmir, Türkiye 2 Aydın Devlet Hastanesi, Tıbbi Onkoloji, Aydın, Türkiye 3 Katip Çelebi Üniversitesi Atatürk Eğitim Ve Araştırma Hastanesi, Tıbbi Onkoloji, İzmir, Türkiye Dergiye Ulaşma Tarihi:20/01/2015 Dergiye Kabul Tarihi:28/05/2015 Doi: 10.5505/AOT.2015.05706 ÖZET Bleomisin’in mukokutanöz yan etkileri, 100 U'den daha yüksek kümülatif dozları alan hastalarda yaygındır. Flagella benzeri hiperpigmentasyon bleomisin kullanımının neden olduğu, vakaların yaklaşık % 8 -20'sinde görülen ilginç bir cilt reaksiyonudur. Mekanizması bilinmemektedir. Tanı karakteristik klinik görünüme dayanmaktadır. Hiperpigmente cilt lezyonlarının histolojik incelemesi, bazal keratinositlerde artmış melanin içeriğini ortaya koymaktadır. Hafif vakalar antihistaminiklere ve/veya sistemik steroide yanıt verir fakat birçok vakada ilacın kesilmesi gerekebilir. Biz rölatif olarak daha düşük (kümülatif dozlar 30 ve 38 U) dozlarla bleomisin kaynaklı flagella benzeri hiperpigmentasyonu olan 2 vaka sunuyoruz. Bleomisin kullanan hastalarda hiç de nadir olmayan bu komplikasyonu klinisyenler akılda bulundurmalıdırlar. Anahtar Kelimeler: Hiperpigmentasyon, Bileomisin, Cilt ABSTRACT Mucocutaneus side effects of bleomycin therapy are common in patients receiving cumulative doses greater than 100 U (100 mg). Flagellate hyperpigmentation is an interesting cutaneus reaction caused by bleomycin use, and is seen in about 8-20% of cases. The mechanism is unknown. Diagnosis is based on its characteristic clinical appearance. Histological examination of hyperpigmented skin lesions has demonstrated increased melanin content in basal keratinocytes. It has been suggested that mild cases may respond to antihistamines and ⁄ or systemic steroids, but in many cases discontinuation of the drug may be necessary. We present two patients (cumulative doses of 30 and 38 U) that developed bleomycin-induced flagellate hyperpigmentation with relatively low doses. Because the condition is not uncommon in patients who are using this drug, the clinician should be mindful of this complication. Key words: Hyperpigmentation, Bleomycin, Skin Introduction Flagellate hyperpigmentation (FH) is reported as a rare cutaneous complication following bleomycin therapy (1). It occurs in 8-20% of the patients undergone bleomycin treatment, and its mechanism of causing the complication stands unknown (2). Mostly, the complication is considered to happen dose-dependent and generally occurs when the cumulative dose is between 100 and 300 U (3). We, here, present two patients who developed FH after receiving low dose (30 and 38 U) of bleomycin treatment. Case I A 78-year-old man, diagnosed with stage III lymphocyte-rich Hodgkin’s lymphoma, was started on chemotherapy with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). Ten days after the second cycle of chemotherapy (cumulative dose of bleomycin at 38 U), some pruritic, linear and erythematous lesions developed on his knees, shoulders, and upper chest (Figure 1). The patient was treated with an intravenous antihistamine and methylprednisolone (16 mg for 2 days), which temporarily reduced the erythema and relieved the itching problem. However, the streaky erythematous lesions progressed over the course of several days as