A Case of Methotrexate-induced Bullous Acral Erythema: DISCUSSION part 2
Therapy is generally supportive and consists of emollients and cold compressives. In some cases, bullous acral lesions can preclude further use of the causative agent due to severe pain and impairment of function. When future cycles of the agent are necessary, patient-controlled analgesia, systemic methylprednisone, pyridoxine, and supportive topical treatments have been used to treat acral erythema. In patients with known bullous acral erythema, short courses of intravenous dexame- thasone given at each infusion of the causative agent seem to limit bullae formation, narcotic use, and functional impairment. But the data is anecdotal and no controlled studies have been performed. Our patient obtained substantial benefit from supportive topical steroids in the management of his acute symptoms.
It is often difficult to distinguish between CIAE and acute graft versus host disease (GVHD) in the early stages and they sometimes occur together, making correct diagnosis particularly challenging. However, acute GVHD can arise almost exclusively in allograft recipients, and is often associated with gastrointestinal disturbance and liver dysfunction. Although both conditions demonstrate acral erythema, the rash of acute GVHD typically appears on the face and upper chest first, and spreads to acral areas later. It may also become generalized and develop a papular component. Most importantly, whereas CIAE resolves without aggressive management and does not pose a threat to the patient’s health, acute GVHD requires prompt intervention and may be fatal.
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High-dose methotrexate-induced acral erythema is not a common event. In the patient with spontaneous self-limiting evolution of the cutaneous lesions and without other signs of methotrexate toxicity, the chemotherapeutic schedule should not be modified in almost cases.
Herein, we report a case of a 65-year-old man who developed bullous acral erythema after the administration of high-dose methotrexate for the treatment of Non-Hodgkin’s lymphoma.