Bleomycin-Induced Flagellate Hyperpigmentation

A 39-year-old woman with a long-standing vascular malformation of the posterior tongue underwent intralesional sclerotherapy with a single dose of bleomycin. Within 1 week after treatment, painless, nonpruritic, flagellate hyperpigmentation developed on her trunk. She had no alopecia and no changes in the appearance of nails or mucosa. She reported having no dyspnea or pulmonary symptoms.
Bleomycin is a glycopeptide antibiotic commonly used for chemical pleurodesis, the treatment of cutaneous warts, and the treatment of a variety of cancers. The rate of flagellate hyperpigmentation in patients who are treated with bleomycin may be as high as 20%. Most tissues contain a cysteine proteinase capable of hydrolyzing and inactivating bleomycin. The reduced concentration of bleomycin hydrolase in the skin and lung, as compared with other tissues, may explain the medication's adverse reaction profile.

The patient was counseled that the flagellate hyperpigmentation usually fades over a period of several months after the cessation of the medication. During the past year, the hyperpigmentation in this patient has faded but not yet resolved.