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Dermatology

Asymptomatic Purpuric Eruption on the Scalp of a Middle-aged Man

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

1 Credit CME

JAMA Oncology

Published Online: February 18, 2021

JAMA Oncology Clinical Challenge

Article Information and Disclosures

Evgeniya Teterina Mohammed, MD¹;

Tejesh Patel, MD¹

Author Affiliations

¹Kaplan-Amonette Department of Dermatology, University of Tennessee Health Science Center, Memphis

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A man in his 60s presented to the clinic with a several-day history of nontender, nonitchy purpuric rash on his scalp. The patient denied using any over-the-counter or prescription topicals at the affected sites before the onset of the eruption except for petroleum jelly. His medical history was significant for chronic lymphocytic leukemia (CLL) and allergic contact dermatitis. The patient reported being started on ibrutinib and allopurinol therapy 6 weeks prior to the rash onset for treatment of CLL. Physical examination revealed multiple purpuric, nonblanchable macules and patches on the frontal, vertex, temporal, and parietal scalp (Figure, A). A punch biopsy specimen from the scalp was obtained for histopathologic analysis (Figure, B).

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C. Ibrutinib-induced toxic effects

Ibrutinib is a selective Bruton tyrosine kinase inhibitor used for treatment of several lymphoproliferative disorders, including CLL, mantle cell lymphoma, marginal zone lymphoma, and Waldenström macroglobulinemia. Skin eruptions represent a frequent adverse effect of the medication and are seen in up to 47% of patients who take it.¹

A retrospective cohort study by Iberri et al² reported 2 main types of skin eruptions associated with ibrutinib use: an asymptomatic, nonpalpable, petechial rash, and a palpable, purpuric eruption resembling leukocytoclastic vasculitis (LCV). The nonpalpable eruption had late rash onset (80 days after initiation of the drug on average) and mild associated symptoms. The palpable eruption was associated with earlier rash onset (15 days after initiation of the drug on average) and worse severity, requiring temporary interruption of ibrutinib therapy in some of the patients. All the patients who required temporary interruption of therapy were able to resume ibrutinib.² Histopathology of the eruptions revealed perivascular and interstitial inflammation and erythrocyte extravasation with no evidence of LCV.

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Article Information

Corresponding Author: Evgeniya Teterina Mohammed, MD, Kaplan-Amonette Department of Dermatology, University of Tennessee Health Science Center, 930 Madison Ave, Ste 840, Memphis, TN 38163 (eteteri1@uthsc.edu).

Published Online: February 18, 2021. doi:10.1001/jamaoncol.2020.6773

Conflict of Interest Disclosures: None reported.

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

References

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Iberri DJ , Kwong B , Stevens L , et al. Ibrutinib-associated rash: a single-centre experience of clinicopathological features and management. Br J Haematol. 2018;180(1):164-166. doi:10.1111/bjh.14302 PubMed Google Scholar Crossref

Parra CE , Newsom E , Lee EH , Allan JN , Minkis K . Association of Ibrutinib Treatment With Bleeding Complications in Cutaneous Surgery. JAMA Dermatol. 2017;153(10):1069-1070. doi:10.1001/jamadermatol.2017.1877 PubMed Google Scholar Crossref

Byrd JC , Furman RR , Coutre SE , et al. Targeting BTK with ibrutinib in relapsed chronic lymphocytic leukemia. N Engl J Med. 2013;369(1):32-42. doi:10.1056/NEJMoa1215637 PubMed Google Scholar Crossref

Singer S , Tan SY , Dewan AK , et al. Cutaneous eruptions from ibrutinib resembling egfr inhibitor-induced dermatologic adverse events. J Am Acad Dermatol. 2019;S0190-9622(19)33308-0. doi:10.1016/j.jaad.2019.12.031 PubMed Google Scholar

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Fang SY , Wu CS , Liu YS , Wei KC . Epidermal growth factor receptor (EGFR) inhibitor induced purpuric drug eruption: three case reports. Medicine (Baltimore). 2019;98(47):e18112. doi:10.1097/MD.0000000000018112 PubMed Google Scholar

Goeser MR , Laniosz V , Wetter DA . A practical approach to the diagnosis, evaluation, and management of cutaneous small-vessel vasculitis. Am J Clin Dermatol. 2014;15(4):299-306. doi:10.1007/s40257-014-0076-6 PubMed Google Scholar Crossref

Cines DB , Blanchette VS . Immune thrombocytopenic purpura. N Engl J Med. 2002;346(13):995-1008. doi:10.1056/NEJMra010501 PubMed Google Scholar Crossref

Joly BS , Coppo P , Veyradier A . Thrombotic thrombocytopenic purpura. Blood. 2017;129(21):2836-2846. doi:10.1182/blood-2016-10-709857 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.