Pharmacology and therapeutics Acute and severe acne in a patient treated with bevacizumab Ana Marı´a Molina-Ruiz 1 , MD, Manuel Domine 1 , MD, and Luis Requena 2 , MD Departments of 1 Dermatology and 2 Oncology, Fundacio ´n Jime ´nez Dı ´az, Universidad Auto ´ noma Madrid (Jime ´nez Dı ´az Foundation, Autonomous University of Madrid), Madrid, Spain Correspondence Ana Marı ´a Molina-Ruiz, MD Department of Dermatology Fundacio ´n Jime ´nez Dı ´az Avenida Reyes Cato ´licos 2 28040 Madrid Spain E-mail: anamaria.molinaruiz@ gmail.com; amolinar@fjd.es Conflicts of interest: None. Abstract Background Bevacizumab is a recombinant, humanized monoclonal antibody against vascular endothelial growth factor (VEGF) that inhibits angiogenesis. Bevacizumab is typically well tolerated; its major side effects include hypertension, proteinuria, bleeding, gastrointestinal perforation, and arterial thrombotic events, among others. Cutaneous side effects associated with the use of bevacizumab are rare and involve mainly itching and ex- foliative dermatitis. Nonspecific skin rash and acneiform eruptions have recently been described in patients following infusion of bevacizumab. Methods Findings in a 52-year-old patient with stage IV lung cancer with brain metastasis, who developed severe, acute, and persistent acne after intravenous (IV) infusion of bev- acizumab, are examined. Results The cutaneous eruption was classified as true acne rather than as an acneiform eruption because all cutaneous lesions of acne, namely comedones, inflammatory papules, and pustules, were present. Conclusions To the authors’ knowledge, this is the first report of an association between acne and IV administration of bevacizumab. Introduction Bevacizumab is a humanized monoclonal antibody that targets vascular endothelial growth factor (VEGF). It is used in the treatment of several cancers and ophthalmo- logic diseases. The spectrum of cutaneous adverse effects associated with the use of bevacizumab is con- siderably narrower than that seen with epidermal growth factor receptor (EGFR) inhibitor drugs. It includes itching, exfoliative dermatitis, skin dryness, skin discoloration, impaired wound healing, and stoma- titis. 1 Recent reports describe nonspecific as well as acneiform eruptions in patients receiving bevacizumab, both with systemic 2–4 and intravitreal 5,6 administration. We report a case of severe and persistent authentic acne in a patient with metastatic lung cancer treated with bevacizumab. To our knowledge, this is the first report of an association between true acne and IV bev- acizumab. Materials and methods A 52-year-old man with no significant past medical history was diagnosed with lung adenocarcinoma and brain metastasis in December 2010. Palliative holocranial radiotherapy was performed in January 2011, and six cycles of chemotherapy with docetaxel, carboplatin, and bevacizumab were administered from February to June in the same year. The patient’s lung tumor decreased significantly in size after three cycles, but one month after the initial IV infusion of bevacizumab, the patient developed a rapidly progressive and painful cutaneous eruption located on the face, neck, trunk, and upper arms. The patient was referred to our dermatology department because the skin rash persisted two months after treatment had ended. Physical examination revealed the eruption to consist of erythematous follicular papules, pustules, inflammatory nodules, and open comedones, some of which had healed to leave scars (Fig. 1). The lesions were located mainly on the forehead, chin, neck, chest, shoulders, and upper back. Further physical examination was unremarkable. Two skin punch biopsies were performed (Fig. 2). The first biopsy was taken from a cluster of comedones located on the forehead. It showed a cystic, dilated, follicular infundibulum filled with basophilic, basket-weave, orthokeratotic keratin, and numerous bacteria. The second biopsy was taken from an inflammatory nodule located on the chest and revealed suppurative infundibulofolliculitis. Based on these clinical and histopathologic findings, a diagnosis of bevacizumab-induced severe acne was established. Treatment with oral doxycyclin and clindamycin gel was started. This improved the symptoms but did not cause the lesions to disappear. In September 2011, progression of lung cancer was observed, and a second-line therapy with erlotinib was started. 486 International Journal of Dermatology 2013, 52, 486–490 ª 2013 The International Society of Dermatology