2-Chlorodeoxyadenosine-Associated Transient Acantholytic Dermatosis in Hairy Cell Leukemia Patients

Field: Medicine (Health Sciences)

To the Editor: Transient acantholytic dermatosis (Grover's disease) is typically a self-limited, pruritic papulovesicular condition that occurs most commonly in men older than 40 years; associated, potentially etiologic, factors include excessive heat (prolonged febrile episode) and excessive perspiration (sweating) (1). Hospitalization and chronic confinement to bed (occlusive immobility) have also been observed as possible disease-related factors in oncology patients who develop transient acantholytic dermatosis (2). In cancer patients, transient acantholytic dermatosis has been noted to occur in four settings: (1) idiopathic, (2) after antineoplastic therapy, (3) after radiation therapy, and (4) paraneoplastic; in the latter situation, either the appearance of the dermatosis has coincided with the discovery of the associated malignancy or the resolution of the dermatosis has corresponded with the favorable response of the malignancy to antineoplastic therapy or both (3). Harvell et al. (4) have recently reported a Grover's-like disease in two men with non-Hodgkin's lymphoma and two men with myelogenous leukemia. The cutaneous lesions appeared within 11 to 19 days after induction therapy (either chemotherapy alone or combination chemotherapy-irradiation) for either bone marrow transplantation or autologous peripheral blood stem cell infusion. The dermatosis resolved spontaneously (two patients) or after topical treatment with a mid-potency corticosteroid cream (triamcinolone acetonide 0.1 percent cream) (one patient) or antiseptic (chlorhexidine gluconate [Hibiclens]) washes (one patient). We have recently described two men with hairy cell leukemia who developed biopsy-confirmed transient acantholytic dermatosis that was temporally associated with their receiving leukemia-directed therapy with 2-chlorodeoxyadenosine (Table 1)(5). Similar to three of Harvell et al.'s (4) patients, both of our patients were febrile prior to the appearance of their skin lesions. In the oncology patient with fever and a new cutaneous eruption, the clinical differential diagnosis includes bacterial, fungal, and viral infection; indeed, we were consulted to evaluate "an acyclovir-resistant disseminated herpes virus infection" in one of our patients.TABLE 1: Characteristics of hairy cell leukemia patients who developed transient acantholytic dermatosis after treatment with 2-chlorodeoxyadenosine* In contrast to patients with idiopathic transient acantholytic dermatosis, Harvell et al. (4) noted that two of their patients had scalp lesions and that the eruption was nonpruritic in three of their patients. Dermatosis-associated lesions were present on the back of both of our patients; in addition, one of the patients also had lesions on his chest and scalp. Also, one of our patients' lesions were nonpruritic. In conclusion, we concur that transient acantholytic dermatosis should be added to the differential diagnosis of cutaneous eruptions in the posttransplant period. In addition, we also recommend that this dermatosis be considered as a diagnostic possibility in the febrile oncology patient. However, because the morphology of transient acantholytic dermatosis lesions can mimic a systemic infection, a lesional biopsy can be helpful to confirm the diagnosis and exclude other conditions (including infection) which may occur in cancer patients. Philip R. Cohen, M.D. Departments of Dermatology and Pathology; The University of Texas-Houston Medical School and; Department of Medical Specialties (Section of Dermatology); The University of Texas M.D. Anderson Cancer Center; Houston, Texas Razelle Kurzrock, M.D. Department of Bioimmunotherapy; The University of Texas M.D. Anderson Cancer Center; Houston, Texas