The expanded use of targeted anticancer agents such as sorafenib has revealed a growing spectrum of adverse cutaneous eruptions. We describe 3 patients with sorafenib-induced psoriasiform dermatitis and review the literature of only 10 other similar reported cases based on a search of PubMed, Web of Science, and American Society of Clinical Oncology abstracts using the terms psoriasis or psoriasiform dermatitis and sorafenib.1-10 We seek to increase awareness of this particular drug eruption in response to sorafenib and to describe potential effective treatment options, especially when sorafenib cannot be discontinued.
Case Reports
Patient 1
A 68-year-old man with chronic hepatitis B infection and hepatocellular carcinoma (HCC) was started on sorafenib 400 mg daily. After 2 months of treatment, he developed painful hyperkeratotic lesions on the bilateral palms and soles with formation of calluses and superficial blisters on an erythematous base that was consistent with hand-foot skin reaction (HFSR). He also had numerous erythematous thin papules and plaques with adherent white scale and yellow crust on the bilateral thighs, lower legs, forearms, dorsal hands, abdomen, back, and buttocks (Figure 1). He had no personal or family history of psoriasis, and blood tests were unremarkable. Histologic analysis of punch biopsies from the buttocks and right leg revealed focal parakeratosis with neutrophils and serous crust, acanthosis, mild spongiosis, and lymphocytes at the dermoepidermal junction and surrounding dermal vessels, consistent with psoriasiform dermatitis (Figure 2). Sorafenib was discontinued and the eruption began to resolve within a week. A lower dose of sorafenib (200 mg daily) was attempted and the psoriasiform eruption recurred.
Figure 1. Sorafenib-induced plaque-type psoriasis. Erythematous thin papules and plaques with adherent white scale and yellow crust on the right lower leg (patient 1).
Figure 2. Microscopic findings of a lesion from patient 1 revealed psoriasiform hyperplasia with parakeratosis, mild spongiosis, and lymphocytes at the dermoepidermal junction and surrounding dermal vessels (H&E, original magnification ×100).
Patient 2
An 82-year-old man with chronic hepatitis B infection and HCC with lung metastasis was treated with sorafenib 400 mg daily. One week after treatment, he developed painful, thick, erythematous lesions on acral surfaces, consistent with HFSR. The sorafenib dose was decreased to 200 mg daily and HFSR resolved. Four months later, he developed well-demarcated, erythematous, scaly plaques with peripheral pustules on the right thigh (Figure 3) and right shin. He had no personal or family history of psoriasis, and blood tests were unremarkable. Samples from the pustules were taken for bacterial culture and fungal stain, but both were negative. Histologic analysis of a punch biopsy from the right thigh revealed necrotic parakeratosis, spongiform pustules, mild acanthosis, and a perivascular lymphocytic infiltrate with many neutrophils in the dermis. These findings suggested a diagnosis of pustular psoriasis, pustular drug eruption, or acute generalized exanthematous pustulosis. Treatment was initiated with mometasone cream. The patient subsequently developed hemoptysis and ascites from sorafenib. Sorafenib was discontinued and his skin eruption gradually resolved.
Figure 3. Sorafenib-induced pustular psoriasis. Erythematous scaly plaque with pustules along the periphery on the right lateral thigh (patient 2).
Patient 3
A 45-year-old woman with history of acute myeloid leukemia (AML) was started on sorafenib 200 mg twice daily as part of a clinical pilot study to maintain remission following an allogeneic bone marrow transplant. Four months after beginning sorafenib, the patient developed multiple well-defined, erythematous, thin papules and plaques with overlying flaky white scale on the bilateral upper extremities and trunk and scattered on the bilateral upper thighs (Figure 4) along with abdominal pain. Her other medical history, physical findings, and laboratory results were unremarkable, and there was no personal or family history of psoriasis. Her oncologist suspected that the eruption and symptoms were due to sorafenib and reduced the dose to 200 mg daily. Histologic analysis of a punch biopsy specimen revealed subcorneal neutrophilic collections with mild spongiosis and mild perivascular inflammatory infiltrate composed of lymphocytes and neutrophils (Figure 5). Direct immunofluorescence was negative for antibody or complement deposition. A bone marrow biopsy was negative for AML recurrence. The patient was continued on sorafenib to prevent AML recurrence, and she was started on triamcinolone cream 0.1% twice daily. Two weeks later, the eruption worsened and the patient was started on oral hydroxyzine for pruritus and narrowband UVB (NB-UVB) phototherapy 3 times a week. After 9 applications of NB-UVB phototherapy, there was complete resolution of the eruption.
Figure 4. Sorafenib-induced psoriasiform drug eruption. Numerous erythematous scaly papules and plaques on the right ventral forearm (patient 3).
Figure 5. Microscopic findings of a lesion from patient 3 showed a subcorneal neutrophilic collection, acanthosis, mild spongiosis, and mild perivascular inflammatory infiltrate (H&E, original magnification ×200).