Flagellate Rash and Anagen Effluvium in a Patient of Hodgkin’s Lymphoma

Dear Editor, Bleomycin-induced flagellate dermatitis is a distinctive but uncommon mucocutaneous adverse reaction characterized by pruritic linear erythematous streaks progressing to hyperpigmentation. Although clinically recognizable, detailed dermoscopic, trichoscopic, and histopathological correlations remain sparsely described in the literature. We report the case of a young male with Hodgkin’s lymphoma who developed bleomycin-induced flagellate dermatitis associated with chemotherapy-induced anagen effluvium, highlighting the clinicopathological and trichoscopic spectrum of this rare clinical entity. A male in his 20s presented with severely pruritic, progressive linear skin lesions for 1 month. He was a diagnosed case of stage IV mixed-cellularity Hodgkin’s lymphoma and had received two cycles of adriamycin (36.2 mg), bleomycin (14.5 units), vinblastine (8.7 mg), and dacarbazine (545 mg; ABVD regimen). He additionally complained of excessive hair loss with decreased hair growth following chemotherapy initiation. There was no prior history of similar lesions or any significant comorbidity. Cutaneous examination revealed multiple well-defined erythematous linear streaks and plaques with central hyperpigmentation arranged in a characteristic “whip-like” pattern over the neck, trunk, and upper extremities [Figure 1A and B]. Scalp examination showed diffuse nonscarring alopecia with fragile, lusterless hairs [Figure 2A]. Nail examination demonstrated melanonychia [Figure 2B]. Mucosal examination yielded unremarkable results. Trichoscopy (Dermlite DL4, ×10 polarized mode) revealed exclamation mark hairs, black dots, Pohl–Pinkus constrictions, and tulipoid hairs with preserved follicular openings and absence of yellow dots [Figure 3A]. Trichogram demonstrated dystrophic anagen hairs with fractured hair shafts [Figure 3B and C], consistent with anagen effluvium. Histopathological examination of a representative plaque showed intact stratum corneum with epidermal spongiosis and apoptotic keratinocytes. The dermis revealed dilated blood vessels with perivascular inflammatory infiltrate composed predominantly of lymphocytes, histiocytes, and eosinophils [Figure 4A and B]. The combination of eosinophilic infiltrate and epidermal spongiosis supported a drug-induced inflammatory reaction. Based on the temporal association, clinical morphology, trichoscopic findings, and histopathology, a diagnosis of bleomycin-induced flagellate dermatitis with chemotherapy-induced anagen effluvium was established. The Naranjo Adverse Drug Reaction Probability score was 8, indicating a probable drug reaction. The adverse event was reported to the Pharmacovigilance Programme of India (PvPI Report No. IN-IPC-301051650). According to World Health Organisation-Uppsala Monitoring Centre criteria, the causality was categorized as certain, and the severity was graded as mild (Level I) using the modified Hartwig and Siegel scale. In consultation with the hematology team, bleomycin was continued with close dermatological monitoring. The patient was managed symptomatically with topical corticosteroids and oral antihistamines and is under follow-up.Figure 1: Erythematous to hyperpigmented linear streaks and plaques in “whip-like” pattern over (A) the upper back and (B) dorsum of both handsFigure 2: (A) Diffuse thinning and fragile hairs over the scalp and (B) nail examination showing melanonychiaFigure 3: (A) Trichoscopy (polarized, ×10 magnification) showed exclamation mark hairs (green arrow), black dots (red circle), Pohl–Pinkus constriction (blue arrow), and tulipoid hair (red arrow) with intact follicular opening and absence of yellow dots. (B) Trichogram revealed a fractured hair shaft (blue arrow). (C) Dystrophic anagen hairs with an intact outer root sheath (Dermlite DL4, 3 Gen, CA, USA ×10 magnification, polarized mode)Figure 4: (A) Epidermis with spongiosis (black arrow) and apoptotic keratinocyte (blue arrow). Dermis showing eosinophils (H&E ×100 magnification). (B) Dermis with dilated blood vessels (blue arrow) with perivascular eosinophils (red arrow) and lymphocytes (H&E ×400 magnification)Bleomycin sulfate is a cytotoxic glycopeptide antibiotic derived from Streptomyces verticillus, commonly used in lymphomas and germ cell tumors.[1] Flagellate dermatitis is one of its most characteristic cutaneous adverse effects, with the reported incidence ranging from 8% to 66%.[2] The rash typically appears after cumulative doses around 100 U but may occur at much lower doses, including after intralesional therapy.[3] Proposed pathogenic mechanisms include “heat recall,” microtrauma-induced leakage of the drug into skin, inflammatory oncotaxis, and delayed epidermal turnover.[4] The novelty of the present case lies in the simultaneous documentation of bleomycin-induced flagellate dermatitis with anagen effluvium, along with a detailed trichoscopic and histopathological correlation. Trichoscopic findings such as Pohl–Pinkus constrictions, tulipoid hairs, and dystrophic anagen hairs have rarely been emphasized in association with bleomycin therapy. Additionally, the dermoscopic correlation of alternating erythema and hyperpigmentation with histological vascular dilatation and basal pigmentation adds further information to the evolving morphology of flagellate dermatitis. Histopathological studies in bleomycin-induced flagellate erythema have demonstrated spongiosis and dermal eosinophilia, findings mirrored in our patient.[5] In conclusion, early recognition of this distinctive adverse reaction is important to prevent unnecessary investigations, reassure patients regarding reversibility, and facilitate timely symptomatic management. Awareness among dermatologists and oncologists regarding its trichoscopic and histopathological spectrum may aid in the prompt diagnosis and reporting of this uncommon toxicity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.