BI27: Two cases of capecitabine-induced subacute cutaneous lupus erythematosus

Published Date: 05th July 2022

Publication Authors: Winters S, Hindle E

Abstract
Capecitabine-induced subacute cutaneous lupus erythematosus is a documented but seemingly underappreciated phenomenon. We report our experience of two cases reviewed in a specialist immunochemotherapy dermatology clinic. A 73-year-old woman with a background of stage 4 oesophageal cancer presented with a rapidly progressive pruritic eruption. She had received one cycle of combination chemotherapy with oxaliplatin and capecitabine in the month prior, but subsequently developed laryngeal spasm secondary to oxaliplatin, which was discontinued. Treatment was continued with single-agent capecitabine for one further cycle. Approximately 2 weeks later she developed a florid, scaly, annular erythematous eruption over the sun-exposed regions of the forearms, anterior chest, upper back and lower limbs. Skin biopsy revealed hyperkeratosis, parakeratosis and an atrophic epidermis with apoptotic basal keratinocytes and pigment incontinence at the papillary dermis, confirming subacute cutaneous lupus erythematosus (SCLE) attributed to capecitabine. Serology confirmed the presence of antinuclear antibodies (1 : 2560; homogeneous speckled) and anti-Ro antibodies. Hydroxychloroquine 200 mg once daily was commenced, inducing a partial response. The frequency was increased to twice daily, resulting in clearance of the rash. A 70-year-old woman with a background of stage 4 breast cancer was referred to the clinic with a 4-month history of a pruritic, tender eruption composed of erythematous, scaly plaques and papules in a photosensitive distribution affecting her chest, forearms and upper back. She had received palliative treatment with hormone therapy, radiotherapy and various chemotherapeutic agents, the most recent of which included cycles of capecitabine over a 2-year period, with a final dose administered 7 months prior to her cutaneous manifestations. Skin biopsy revealed hyperkeratosis, basal vacuolar change, apoptotic keratinocytes and moderate inflammation at the dermoepidermal junction with pigment incontinence, confirming SCLE postulated to be secondary to capecitabine. Treatment with hydroxychloroquine 200 mg once daily was initiated alongside broad-spectrum ultraviolet protection, potent topical steroids and menthol in aqueous cream 5%. SCLE is a subtype of lupus erythematosus, characterized by a photosensitive, nonscarring papulosquamous eruption, in which a proportion of cases are known to be drug induced. The most common culprits include thiazides, terbinafine and calcium channel blockers. Capecitabine, a chemotherapeutic agent employed in the treatment of several types of cancer, is a lesser-known causative agent and, to date, only single case reports exist within the literature. These cases highlight the variability in incubation time from trigger to onset of rash. Owing to the increasing use of capecitabine in cancer therapy, an awareness of this under-recognized cutaneous reaction is of paramount importance in this vulnerable cohort of patients.

Winters, S and Hindle, E. (2022). BI27: Two cases of capecitabine-induced subacute cutaneous lupus erythematosus. British Journal of Dermatology. 187(S1), p.116. [Online]. Available at: https://onlinelibrary.wiley.com/doi/10.1111/bjd.21369 [Accessed 12 August 2022]

 

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