Manifestaciones mucocutáneas de intoxicación por metotrexato / 4pp Mucocutaneous manifestations of methotrexate toxicity

El metotrexato es un antimetabolito análogo al ácido fólico que inhibe competitivamente la enzima dihidrofolato reductasa y timidilato sintetasa, indispensables para la síntesis de ADN y ARN. Se utiliza ampliamente en dermatología y sus efectos adversos en la piel y mucosas son variados, incluyendo reacciones leves y graves. Las erosiones y úlceras cutáneas como manifestación de citotoxicidad por metotrexato son infrecuentes y representarían un signo cutáneo temprano de pancitopenia por toxicidad medular secundaria a dicha droga. En la mayoría de los casos existen enfermedades cutáneas previas a la ulceración, principalmente psoriasis. En ausencia de dermatitis subyacente, la presencia de ulceraciones es excepcional. Se presentan ocho casos de pacientes con signos cutáneos de intoxicación por metotrexato, con y sin dermatosis previas. En la mayoría hubo asociación de mucositis y compromiso medular. Se recomiendan pautas de tratamiento.

Methotrexate is an antimetabolite analog to folic acid that competitively inhibits the enzyme dihydrofolate reductase and thymidylate synthetase, essential for the synthesis of DNA and RNA. It is widely used in dermatology and its adverse effects on the skin and mucous membranes are varied, including mild and severe reactions. The appearance of erosions and skin ulcers as a manifestation of methotrexate cytotoxicity are quite infrequent. These would represent an early cutaneous sign of pancytopenia due to marrow toxicity secondary to this drug. In most of the cases there are cutaneous diseases prior to ulceration, mainly psoriasis. In the absence of underlying dermatitis, the presence of ulcerations is very rare. We present eight cases of patients with cutaneous signs of methotrexate poisoning, with and without previous dermatoses. Most of them associated mucositis and bone marrow involvement. Treatment guidelines are recommended.

Ulcerations due to methotrexate toxicity in a psoriasis patient

Abstract: Methotrexate is one of the most used drugs in the treatment of psoriasis with indication of systemic therapy. Cutaneous and mucous side effects are described by pharmacological characteristics of the drug itself or due to overdose. We report the case of a patient with ulcerations in oral mucosa and psoriatic plaques after incorrect use of Methotrexate. Prescribed in a weekly dose, it was used continuously for 10 days and without simultaneous intake of folic acid. It is important to ensure correct comprehension of the prescription.

Úlceras por hidroxiurea en paciente con policitemia vera / Ulcers to hydroxyurea in a patient with polycythemia vera

La hidroxiurea es un agente citostático que inhibe la síntesis de ADN. Se considera el tratamiento de primera línea para algunos trastornos mieloproliferativos, enfermedad de células falciformes, casos severos de psoriasis refractaria y como adyuvante en la terapia de VIH. Se ha informado de que algunos pacientes tratados con hidroxiurea pueden tener úlceras en las extremidades inferiores. Paciente femenino de 67 años de edad con antecedentes de policitemia vera tratada con hidroxiurea durante un año, se deriva a dermatología por presentar úlceras bilaterales en extremidades inferiores. Al examen físico se evidencian dos lesiones ulceradas en la región calcánea. Se realiza una biopsia de piel, y muestra signos no específicos de inflamación. Se decide la interrupción de la hidroxiurea y se inicia la terapia adyuvante con pentoxifilina. Las lesiones se resolvieron en dos meses, dejando una pequeña cicatriz residual. Es importante recordar esta rara complicación inducida por el uso prolongado de la hidroxiurea y, de esta manera, realizar un diagnóstico precoz y tratamiento adecuado, que hasta el momento es básicamente la suspensión de la hidroxiurea.

Hydroxyurea is a cytostatic agent that inhibits DNA synthesis. It is considered the first line treatment for some myeloproliferative disorders, sickle cell disease, severe cases of refractory psoriasis and as adjuvant in VIH therapy. It has been reported that some patients treated with hydroxyurea may have leg ulcers. A 67 year old female patient with a history of polycythemia vera treated with hydroxyurea for a year, is derived to dermatology for presenting bilateral lower extremity ulcers. Physical examination demonstrated two ulcerated lesions in the calcaneal region. A skin biopsy is performed, and it shows non-specific signs of inflammation. Discontinuation of hydroxyurea is decided and initiate adjuvant therapy with pentoxifylline. These ulcerative lesions were resolved within two months, leaving a small residual scar. It is important to remember this rare complication induced by prolonged use of hydroxyurea and thus, early diagnosis and appropriate treatment can be made, which so far is basically the suspension of hydroxyurea.

New drugs, new challenges for dermatologists: mucocutaneous ulcers secondary to everolimus

Everolimus, a mammalian target of rapamycin inhibitor, is an emerging drug, which is being increasingly applied in oncology and solid organ transplantation. Oral ulcers are a frequent side effect associated with this immunosupressor. We report the case of a renal transplant recipient who developed disfiguring oral and perianal ulcers secondary to everolimus's toxicity. This is probably the first report of perianal involvement. Dermatologists need to be aware of the potential mucocutaneous adverse effects related to these new drugs that are becoming evermore common in our clinical practice.

Úlceras acrales por hidroxiurea en paciente con policitemia vera: comunicación de un caso / Acral ulcers associated with hydroxyurea therapy in a patient with polycythemia vera

La hidroxiurea (HU) es una droga antitumoral utilizada principalmente en enfermedades hematológicas. Es generalmente bien tolerada; sin embargo, puede asociarse a efectos adversos mucocutáneos severos, como úlceras acrales. La patogenia de estas úlceras es desconocida, y su aparición se relaciona a la patología de base, tiempo y dosis administrada. Son muy dolorosas, frecuentemente múltiples y por lo general revierten en forma espontánea al suspender el medicamento. La región maleolar es la más comúnmente comprometida. Presentamos el caso de una paciente de sexo femenino, de 64 años, en tratamiento con HU por policitemia vera, que presentó úlceras acrales a los tres años de tratamiento, con excelente evolución tras la suspensión del fármaco. Es fundamental conocer la existencia de estos efectos adversos para sospecharlos precozmente y realizar un oportuno diagnóstico y tratamiento.

Hydroxyurea (HU) is an antitumor drug commonly used in haematological diseases. It is usually well tolerated, however, it may be associated with severe muco-cutaneous side effects such as acral ulcers. The pathogenesis of these ulcers is unknown, and their appearance is related to the main disease, time and dosage. They are very painful, often multiple, an spontenous resolution after drug suspension is observed. The malleolus region is the most common site affected. We present the case of a 64-year-old woman with polycythemia vera treated with HU who developed acral ulcers after 3 years of treatment, with excellent response after drug discontinuation. For an opportune diagnosis and treatment of these side effects, it is very important to know of their existence and suspect that they may appear in advance.

Tratamento das ulceraçöes cutâneas causadas por extravasamento de adriamicina

Säo apresentados seis casos de extravasamento acidental de adriamicina para o tecido celular subcutâneo nas áreas de infusäo, que evoluíram com úlceras de pele. As principais causas desse acidente säo revistas, bem como suas formas de prevençäo, tratamento precoce e as condutas recomendadas quando da ocorrência de necroses teciduais

Toxicidad local con bleomicina / Local toxicity with bleomycin

Presentamos el caso de un niño de 6 años portador de una LLA quien tras la inyección subcutánea de bleomicina desarrolló una lesión necrótica de la piel en el area de la inyección. Describimos el aspecto anatomopatológico de la lesión y hacemos referencia a otros dos reportes de la literatura de esta extremadamente rara complicación