Intertrigo-like dermatitis with pegylated liposomal doxorubicin: diagnosis and management.

Case Report A 52-year-old woman was observed for metastatic breast cancer, which had been diagnosed 14 years before and was initially treated with mastectomy, adjuvant chemotherapy, and radiotherapy. During the following years, the patient presented with multiple local and lymph node recurrences that were treated with surgical excision followed by several lines of chemotherapy, including anthracycline (epirubicin), taxane, vinorelbine, and capecitabine. No skin toxicity was observed as a result of treatment with these different types of chemotherapy. Following the occurrence of lung metastases, treatment with pegylated liposomal doxorubicin (PLD) was initiated at a dose of 40 mg/m intravenously every 4 weeks. A preventive treatment for palmar-plantar eythrodysesthesia (PPE) was initiated at the start of chemotherapy with the use of frozen gloves and socks during the infusion and daily application of emollient creams. Three weeks after the third cycle, the patient developed erosive and desquamative erythematous lesions that were located in the abdominal and axillary regions, sparing the bottom of the folds (Fig 1). Neither mucosal lesions nor palmar or plantar involvement were observed. The patient was apyretic. The lesions were nonpruriginous but were painful and caused an alteration in quality of life and functional limitations during daily activities (toxicity grade 2, according to the basic scale from the Common Terminology Criteria for Adverse Events, version 4). Histology from a biopsy specimen of a lesion in the axillary area revealed unspecific changes: parakeratosis and moderate neutrophil infiltrate in the stratum corneum (Fig 2A), vacuolar degeneration at the basal layer of the epidermis, dermal edema with perivascular lymphocytic infiltrate within papillary dermis (Fig 2B). Periodic acid staining was negative, excluding a fungal infection. Our diagnosis was cutaneous toxicity caused by PLD, which is described in the literature using the term intertrigo-like dermatitis. The fourth cycle of chemotherapy was delayed for a week. Curative treatment with topical and systemic corticosteroids was initiated for a total duration of 1 week: topical clobetasol propionate twice daily and oral prednisone at a dose of 2 mg/kg per day with a rapid gradual discontinuation (Table 1). The lesions responded well to treatment with complete remission after 1 week. To continue the chemotherapy without dose reduction, we proposed a prophylactic treatment during all subsequent cycles: oral corticosteroid at a dose of 1 mg/kg per day with rapid discontinuation for a total duration of 6 days, and topical corticosteroids (clobetasol propionate) applied systematically on the morning before the PLD infusion and for 3 weeks in the previously involved areas (axilla and abdominal belt region), even in the absence of a recurrence of skin lesions (Table 1). With these preventive measures, new skin adverse effects were not observed and the chemotherapy was continued without dose reduction or lengthening of the treatment intervals for three additional cycles. PLD was then discontinued because of cancer progression.