Drug-induced acneiform papulopustolar rash

Folliculitis induced by therapy with the EGFR-blocking monoclonal antibody panitumumab

Symptoms/signs

52-year-old female patient.
She reports that a rash appeared on her face and torso about 15 days ago.

Patient photographs

Clinical presentation

Physical examination of the skin revealed intensely erythematous follicular papules and pustules with a monomorphic appearance on the face and neckline. No comedones are observed.

Medical history

Following a diagnosis of stage IV adenocarcinoma of the colon, therapy was initiated with the FOLFOX combination (FOLinic acid, Fluorouracyl, OXaliplatin) + panitumumab. The latter is a monoclonal antibody that binds to the epidermal growth factor receptor (EGFR).

Differential diagnosis

  • Drug-induced folliculitis (acneiform rash)

  • Bacterial folliculitis

  • Acne vulgaris

Diagnostic tests

Bacterial culture from a pustule shows sterile content.

Description of the disease

Acneiform rashes are increasingly observed following the introduction of EGFR inhibitors into cancer therapy; globally they account for approximately 1% of drug-induced skin reactions. Other drugs associated with this clinical scenario include corticosteroids, also commonly used in oncology, and androgens (in this case, comedones may be observed). The time to onset is variable depending on the drug and dosage: in the case of EGFR inhibitors, the rash can occur acutely after 7-10 days of treatment and affects between 43 and 85% of patients. Results from clinical trials with different EGFR inhibitors showed a positive correlation between the intensity of folliculitis and treatment response and survival.

Pharmacological treatment and patient instructions

Given the extent of skin involvement and the inability to discontinue the responsible drug, the following medical therapy was undertaken:

  • limecycline 300 mg capsules, 1 cps twice daily.

  • clindamycin 1% gel, locally in the evening.

Dermocosmetic management 

  • TOLERIANE Dermo Cleanser, makeup remover with a hypoallergenic formulation specific for sensitive or reactive skin, for morning and evening facial cleansing

  • TOLERIANE Dermallergo Cream, which moisturises, soothes and repairs, with a hypoallergenic formulation for allergy-prone or ultra-sensitive skin, for facial hydration once or twice a day

  • ANTHELIOS UVMUNE 400, SPF 50+ broad-spectrum protection, designed for sensitive or reactive skin, offering protection against UVA, ultra-long UVA, and UVB radiation

Management at home is completed with the use of camouflage make-up.

Follow-up (adjuvant treatment outcomes)

The course of EGFR-induced acneiform rash fluctuates, and, as a rule, improvement is observed with continued anti-EGFR treatment. Topical and systemic antibiotics are used due to their anti-inflammatory activity and are well tolerated when administered for prolonged periods. Drug treatment is supplemented by specific cleansing and topical moisturising, which are highly tolerable and non-irritating, both in the acute phase of the rash and in the subsequent maintenance phase. Finally, daily photoprotection is essential to counteract the formation of post-inflammatory dyschromia on the face.