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Scalp Eruption in a Patient With Metastatic Colon Cancer

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 73-year-old man with metastatic BRAF-mutant colorectal cancer presented with a 1-month history of crusted lesions with purulent drainage on the scalp, with associated pruritus and pain. Five months earlier he began treatment with cetuximab, binimetinib, and encorafenib, complicated by a grade 1 acneiform eruption that was managed with doxycycline hyclate and topical hydrocortisone and clindamycin phosphate. Oncologic therapy was withheld pending further evaluation of the scalp eruption. He had a distant history of actinic keratoses on the scalp treated with liquid nitrogen but otherwise denied previous skin cancer. Examination of the scalp revealed male pattern baldness, diffuse actinic damage, and multiple thick, yellow-brown crusts overlying erosions with purulent drainage (Figure 1). A wound culture was performed and grew methicillin-sensitive Staphylococcus aureus. A shave biopsy was obtained.

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C. Erosive pustular dermatosis

Examination of the biopsy specimen showed an ulcer with folliculitis and impetiginized neutrophilic crust. A 10-day course of cephalexin led to no change in his scalp eruption, confirming the clinical impression of erosive pustular dermatosis of the scalp (EPDS) in the setting of cetuximab therapy. He started a regimen of clobetasol propionate ointment, 0.05%, twice daily and marked improvement was noted at the 1-month follow-up visit (Figure 2). Given the significant improvement, his topical regimen was changed to tacrolimus ointment, 0.1%, on weekdays and clobetasol ointment on weekends to minimize the risk of skin atrophy. He restarted his oncologic treatment regimen shortly after diagnosis and the scalp eruption remained well controlled, with residual scarring and postinflammatory hyperpigmentation. After 3 months without flares, topical therapies were discontinued.

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Article Information

Corresponding Author: Joseph Zikry, MD, Department of Dermatology, Keck School of Medicine, University of Southern California, 1441 Eastlake Ave, Ezralow Tower, Ste 5301, Los Angeles, CA 90033 (zikryj@gmail.com).

Published Online: November 12, 2020. doi:10.1001/jamaoncol.2020.5176

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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