Case and Research Letters
Folliculitis Decalvans Caused by Bacterial Superinfection Secondary to Erlotinib
Foliculitis decalvante por sobreinfección bacteriana secundaria a erlotinib
A. Sahuquillo-Torralba
, B. Escutia-Muñoz, M. Rodríguez-Serna, R. Botella-Estrada
Corresponding author
Servicio de Dermatología, Hospital Universitari i Politécnic La Fe, Valencia, España
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Sahuquillo-Torralba, B. Escutia-Muñoz, M. Rodríguez-Serna, R. Botella-Estrada" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Sahuquillo-Torralba" "email" => array:1 [ 0 => "saucodos@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Escutia-Muñoz" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Rodríguez-Serna" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Botella-Estrada" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitari i Politécnic La Fe, Valencia, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Foliculitis decalvante por sobreinfección bacteriana secundaria a erlotinib" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1200 "Ancho" => 900 "Tamanyo" => 299804 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">De-epithelialized alopecic plaques with a scar-like appearance throughout the scalp, alternating with purulent and macerated areas.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bacterial superinfection associated with epidermal growth factor receptor (EGFR) inhibitors is a recognizable clinical and histopathological entity that can be differentiated from the classic papulopustular rash. The different location and distribution of the lesions, together with an onset that is typically later than that of papulopustular rash, enable it to be distinguished based on clinical findings. Correct diagnosis is essential, since treatment must be selected carefully if we are to prevent severe comorbidities in cancer patients, including the potential risk of sepsis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 66-year-old woman diagnosed with metastatic pulmonary adenocarcinoma who was receiving treatment with erlotinib at an initial dose of 150<span class="elsevierStyleHsp" style=""></span>mg/d presented with grade 1 papulopustular rash that progressed to grade 2 rash during the following 3 weeks. The response to topical corticosteroids combined with doxycycline was poor. Therefore, we decided to reduce the dose of erlotinib to 100<span class="elsevierStyleHsp" style=""></span>mg/d, with good control of the papulopustular lesions. Six months later, the patient was referred to the dermatology outpatient clinic for evaluation of crusted lesions on the scalp that had first appeared 3 months previously. Physical examination revealed generalized swelling throughout the scalp over a confluent and malodorous pustular base. Given the diagnosis of bacterial superinfection associated with erlotinib, we took a sample of the exudate for culture and started doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>hours. Methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> was isolated in culture, and treatment was adjusted according to the antibiogram. However, the patient's condition progressed over the following days, with rapid loss of tufts of hair, leaving de-epithelialized alopecic plaques with a scar-like appearance alternating with pustular areas throughout the scalp (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We made a diagnosis of folliculitis decalvans due to bacterial superinfection associated with erlotinib. The patient died of acute pulmonary thromboembolism a week later.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Bacterial superinfection of papulopustular rash secondary to EGFR inhibitors is not an uncommon complication. According to a study performed in 2010 on a series of 221 patients, the complication affected 29% of those treated with these EGFR inhibitors.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> As for pathophysiology, inhibition of EGFR in keratinocytes leads to epidermal thinning. Furthermore, in vitro evaluation has shown that there is a reduction in the production of antimicrobial peptides and ß-defensins by keratinocytes, as well as inhibition of the activation and proliferation of T lymphocytes.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Braden and Anadkat<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> correctly defined this condition in a study published in 2016 that included 157 patients treated with EGFR inhibitors who had developed classic papulopustular lesions or infections resulting from bacterial superinfection. The authors concluded that up to 23% of patients treated with these inhibitors develop symptoms compatible with bacterial superinfection, especially in the form of folliculitis caused by <span class="elsevierStyleItalic">S aureus</span>. In most cases, bacterial superinfection can be differentiated from papulopustular rash based on 2 criteria: distribution of lesions and time to onset after initiation of cancer treatment. Bacterial superinfection progresses with folliculitis lesions mainly on the abdomen, buttocks, arms, and legs. In contrast, classic papulopustular rash is predominantly cephalic, affecting the upper part of the back and chest, and more intense in seborrheic areas of the center of the face and sternum. As for time to onset after initiation of treatment, the papulopustular rash has a mean latency period of 1.5 weeks, compared with a mean of more than 28 weeks in the case of bacterial superinfection. Therefore, the authors state that we should suspect bacterial superinfection, regardless of the location of the lesions, provided that onset is at least 12 weeks after initiation of cancer treatment. Pruritus and pain may be present in both cases, although pain is much more common in cases of bacterial superinfection.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The treatment of bacterial superinfection requires empirical systemic antibiotics after culture of samples and subsequent adjustment based on the antibiogram. As <span class="elsevierStyleItalic">S aureus</span> is generally the pathogen involved, the recommended empirical treatment is clindamycin or trimethoprim-sulfamethoxazole, thus covering the possibility of community-acquired methicillin-resistant <span class="elsevierStyleItalic">S aureus</span>. Systemic involvement should be ruled out based on the clinical history. If there are good grounds for suspicion of systemic involvement, then a workup based on a laboratory analysis and complete blood count should be performed. It may even be necessary to consider admission to hospital and intravenous antibiotic therapy. Nevertheless, most cases respond to oral therapy at home with close monitoring.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, we present a case of bacterial superinfection associated with erlotinib that manifested as folliculitis decalvans, a complication that has received little attention in the literature.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6–8</span></a> Knowledge of this entity enables the early management necessary to prevent severe local or systemic complications. The disease should be correctly differentiated from the classic papulopustular rash.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "Références" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sahuquillo-Torralba A, Escutia-Muñoz B, Rodríguez-Serna M, Botella-Estrada R. Foliculitis decalvante por sobreinfección bacteriana secundaria a erlotinib. Actas Dermosifiliogr. 2018;109:363–364.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1200 "Ancho" => 900 "Tamanyo" => 299804 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">De-epithelialized alopecic plaques with a scar-like appearance throughout the scalp, alternating with purulent and macerated areas.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Références" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Staphylococcus aureus bacteremia secondary to severe erlotinib skin toxicity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 81 | 40 | 121 |
| 2024 September | 73 | 19 | 92 |
| 2024 August | 109 | 51 | 160 |
| 2024 July | 89 | 29 | 118 |
| 2024 June | 103 | 23 | 126 |
| 2024 May | 78 | 34 | 112 |
| 2024 April | 81 | 21 | 102 |
| 2024 March | 78 | 23 | 101 |
| 2024 February | 51 | 39 | 90 |
| 2024 January | 52 | 27 | 79 |
| 2023 December | 62 | 18 | 80 |
| 2023 November | 76 | 20 | 96 |
| 2023 October | 63 | 21 | 84 |
| 2023 September | 54 | 27 | 81 |
| 2023 August | 41 | 13 | 54 |
| 2023 July | 53 | 26 | 79 |
| 2023 June | 57 | 22 | 79 |
| 2023 May | 58 | 21 | 79 |
| 2023 April | 53 | 26 | 79 |
| 2023 March | 55 | 25 | 80 |
| 2023 February | 42 | 27 | 69 |
| 2023 January | 51 | 34 | 85 |
| 2022 December | 61 | 37 | 98 |
| 2022 November | 27 | 17 | 44 |
| 2022 October | 67 | 27 | 94 |
| 2022 September | 27 | 37 | 64 |
| 2022 August | 50 | 29 | 79 |
| 2022 July | 65 | 35 | 100 |
| 2022 June | 25 | 20 | 45 |
| 2022 May | 64 | 38 | 102 |
| 2022 April | 84 | 44 | 128 |
| 2022 March | 59 | 42 | 101 |
| 2022 February | 51 | 30 | 81 |
| 2022 January | 57 | 39 | 96 |
| 2021 December | 55 | 44 | 99 |
| 2021 November | 57 | 55 | 112 |
| 2021 October | 46 | 51 | 97 |
| 2021 September | 36 | 42 | 78 |
| 2021 August | 49 | 41 | 90 |
| 2021 July | 37 | 37 | 74 |
| 2021 June | 33 | 39 | 72 |
| 2021 May | 51 | 48 | 99 |
| 2021 April | 120 | 90 | 210 |
| 2021 March | 87 | 41 | 128 |
| 2021 February | 72 | 49 | 121 |
| 2021 January | 40 | 47 | 87 |
| 2020 December | 52 | 31 | 83 |
| 2020 November | 38 | 45 | 83 |
| 2020 October | 41 | 21 | 62 |
| 2020 September | 39 | 25 | 64 |
| 2020 August | 35 | 31 | 66 |
| 2020 July | 33 | 23 | 56 |
| 2020 June | 37 | 37 | 74 |
| 2020 May | 39 | 17 | 56 |
| 2020 April | 30 | 18 | 48 |
| 2020 March | 27 | 25 | 52 |
| 2020 February | 2 | 1 | 3 |
| 2020 January | 2 | 0 | 2 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 7 | 0 | 7 |
| 2019 April | 2 | 1 | 3 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 4 | 0 | 4 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 3 | 0 | 3 |
| 2018 May | 1 | 1 | 2 |
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