Scleroderma-like drug reaction to paclitaxel (TaxolR)
Authors: S. Lauchli, R.M. Trueb, M. Fehr, J. Hafner
Journal: British Journal of Dermatology (2002)

Sir, The taxanes, paclitaxel (Taxol®) and docetaxel (Taxotere®) are both highly effective antimicrotubule agents that are widely used in the treatment of metastatic breast cancer and other solid tumours. Both are associated with a number of side‐effects, among them, fluid retention, skin reactions such as erythrodysaesthesia and dose‐limiting neutropenia.1 For docetaxel, there are three case reports describing a total of five patients with extensive cutaneous fibrosis as a side‐effect that was largely reversible in four cases after discontinuation of the drug.2–4 We report a case of extensive scleroderma‐like changes that we believe were induced by paclitaxel. A 66‐year‐old caucasian female had tumour debulking and surgical staging including hysterectomy, bilateral adnexectomy, appendectomy, omentectomy, paraaortal and pelvic lymphadenectomy for poorly differentiated serous‐papillary primary peritoneal carcinoma stage pT3b, pN1(2/23), M0 in June 2000. Optimal tumour debulking was achieved with multiple peritoneal nodules of 3‐mm maximum diameter as residual tumour. Postoperative combination chemotherapy consisted of six cycles of paclitaxel (175 mg m−2) and carboplatin (5 AUC) given every 3 weeks. The treatment was initially well tolerated and currently the patient is under full remission at 15 months' follow‐up. Three months after initiation of chemotherapy, the patient developed extensive cutaneous oedema of the left leg resembling lymphoedema. While antineoplastic chemotherapy was continued, the oedema did not respond to diuretic therapy and manual lymph drainage. After a further 3 months, the skin of both legs started to become sclerotic (Fig. 1). Scleroderma‐like skin tightening extended rapidly to the thighs and arms and was accompanied by dermatogenic contractions of the knees and all finger joints (Fig. 2). Multiple small skin ulcerations of ‘punched‐out’ appearance developed on the legs and calcium deposits occurred on the extensor surface of hands and fingers. The trunk remained unaffected. Raynaud's phenomenon was not noticed and nailfold capillaroscopy was normal. The face showed no teleangiectasias. Slight microstomy and shortening of the frenulum of the tongue were present. On thorough examination there were discrete signs of internal organ involvement. Slight pulmonary fibrosis was detectable on high resolution computed tomography scan, however, the CO‐diffusion capacity was within normal range. Creatinine clearance was slightly reduced at 51 mL min−1. Oesophagomanometry was normal. All relevant autoantibodies, including ANA, anti‐Scl 70, anti‐DNA, anti‐U1‐snRNP and RF were negative. Skin biopsy revealed dermal sclerosis with a mild perivascular lymphohistiocytic infiltrate and entrapment of adnexal structures. All the above changes deteriorated progressively despite discontinuation of paclitaxel and responded poorly to oral steroids (starting at 60 mg daily and tapered) and bath photochemotherapy (PUVA) which were stopped after 8 weeks. Some improvement of joint mobility and wound closure of the majority of the skin ulcers occurred with intense physical therapy and intravenous iloprost, respectively.