Sorafenib
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Psoriasiform eruption (first report), hand-footskin reaction and squamous cell carcinoma: case report A 63-year old man developed psoriasiform eruption, hand-foot-skin reaction (HFSR) and cutaneous squamous cell carcinoma (SCC) during treatment with sorafenib. The man, who had a history of basal cell cancer treated 30 years prior, began receiving sorafenib 400mg twice daily for poorly-differentiated metastatic thyroid cancer. He developed a skin reaction 9 days after starting sorafenib. It was initially characterised by tender erythematous papules and plaques with blisters on the palms and soles. These lesions developed over the next few weeks into hyperkeratotic, well-demarcated callus-like lesions and were localised on plantar pressure areas; these findings were consistent with a clinical diagnosis of HFSR. Nine months later, multiple guttate erythematous papules and plaques with overlying silver scale scattered over the truck, bilateral upper and lower extremities were observed with many becoming confluent over the bilateral popliteal fossa, elbows, inguinal folds and supra-gluteal cleft. A punch biopsy of the left lateral knee revealed psoriasiform epidermal hyperplasia, focal spongiosis, parakeratosis and focal neutrophils in the stratum corneum. A periodic acid Schiff stain returned negative results excluding a fungal infection. A diagnosis of psoriasiform drug eruption was made. Sorafenib was discontinued for 1 month and the man’s symptoms improved with the administration of triamcinolone cream. Sorafenib was then re-initiated at 400 mg/day because of it’s effectiveness in controlling the man’s lung metastases. Nine weeks later, psoriasiform rash was resolved but a new, painful, 1.8 cm dome-shaped hyperkeratotic papule was identified by skin examination on the dorsum of the right hand; it had grown rapidly over several weeks. Welldifferentiated SCC was noted following a shave biopsy. Sorafenib was continued for another month then stopped entirely after the patient developed a tracheo-oesophageal fistula following a surgery. Moh’s surgery was used as treatment for the squamous cell cancer; to date, no recurrences have been observed. Author comment: "The development of a psoriasiform eruption, SCC and HFSR in this patient demonstrates the various manifestations of keratinocyte differentiation/ proliferation dysfunction elicited by sorafenib. Sorafenib is not a classic immunosuppressive agent. . . however, it may impair skin immunosurveillance by decreasing the function of dendritic cells, thus diminishing the induction of the primary immune response and predisposing patients to the development of SCCs." Diamantis ML, et al. Sorafenib-induced psoriasiform eruption in a patient with metastatic thyroid carcinoma. Journal of Drugs in Dermatology 9: 169-71, No. 2, 803013786 Feb 2010 - USA
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Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports of psoriasiform eruption associated with sorafenib. The WHO ADR database contained one report of psoriasis and no repo
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