Flagellant dermatitis L81.4

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Bleomycin hyperpigmentation; Bleomycin-induced flagellate dermatosis; Flagellant hyperpigmentation; Flagellate dermatosis; Hyperpigmentation flagellant; melanodermia factitia

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Flagellant dermatitis (from lat. flagellum 'whip, flagellum') refers to streaky or flat, pigmented, itchy, inflammatory skin lesions described after chemotherapy of tumor patients with bleomycin, more rarely after cyclophosphamide or fluorouracil. The skin lesions occur in predisposed individuals in the sense of a dose-dependent toxic effect, they are reproducible and substance-specific.

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Dose-dependent toxic effect of bleomycin in predisposed patients. Also discussed are postinflammatory hyperpigmentation caused by tumor decay components or allergy induced reaction, stimulation of MSH secretion and structural changes in the ACTH molecule.

Clinical features
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Within minutes to days after the first bleomycin infusion, urticarial exanthema and itching occur. Subsequently (1-3 weeks) development of bizarre pigmentation in the regions of the exanthema or in mechanically stressed areas.

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  • Hyperpigmentation of the basal epithelial layer in the case of clear pigment incontinence, thickened blood vessels with an irregularly contoured endothelial layer and clearly constricted lumen, round cell infiltrates that are thickened perivascularly.
  • Electron microscopy: wall-thickened capillary with narrow residual lumen, villi-like cytoplasmic endothelial spurs, onion-shell-like proliferating pericytes, in between fine granular, electron-tight material; abundant collagen fibrils, metabolically active melanocytes with abundant melanosomes.

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  • After stopping bleomycin, inflammatory changes disappear within a few weeks. However, post-inflammatory pigmentation remains for months or years. Oral antihistamines against itching like Desloratadine (e.g. Aerius) 1-2 tbl/day. In the still florid state short-term external glucocorticoids like Betamethason Lotio R030.
  • Remaining hyperpigmentations can be covered cosmetically ( camouflage), e.g. with Dermacolor.

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  1. Albig J et al (1992) Flagellate hyperpigmentation by bleomycin. dermatologist 43: 376-379
  2. Altmeyer P et al (1984) A contribution to the pathogenesis of cutaneous bleomycin side effects. Act Dermatol 10: 191-196
  3. Duhra P et al (1991) Bleomycin-induced flagellate erythema. Clin Exp Dermatol 16: 216-217
  4. Nayak N et al (2003) Case 2 Bleomycin-induced flagellate dermatosis. Clin Exp Dermatol 28: 105-106


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Last updated on: 29.10.2020