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Acne inversa‐like skin lesions as a potential adverse event during vemurafenib therapy

Cutaneous adverse events are comparatively common on BRAF inhibitor treatment for metastatic melanoma. These include rashes, increased photosensitivity, keratosis pilaris-like skin lesions, acanthomas, keratoacanthomas, squamous cell carcinomas, and secondary melanomas [1–3]. Cystic lesions such as milia and epidermal cysts have also frequently been described. We present the case of a patient on vemurafenib therapy who developed inflammatory nodules reminiscent of acne inversa. A 50-year-old female patient with stage IV BRAF V600E-mutated melanoma was started on vemurafenib (960 mg twice daily), after she had previously received seven cycles of dacarbazine (DTIC) chemotherapy. Besides hepatic and lymph node metastases, she also had peritoneal carcinomatosis and osseous metastases; the latter were treated with bisphosphonates (pamidronate) at four-week intervals. Two weeks after initiation of vemurafenib, she exhibited a pronounced follicular, pustular rash that subsequently resolved on systemic and topical corticosteroid treatment. After a two-week discontinuation of vemurafenib, treatment was resumed at a reduced dose (720 mg twice daily). Sixteen weeks after reintroduction of vemurafenib, she developed slowly progressive, erythematous, very painful inguinal and genital nodules. Following unsuccessful treatment with cefuroxime (500 mg PO twice daily) and a topical disinfectant, we initiated oral antiinflammatory therapy with doxycycline (100 mg twice daily) while continuing vemurafenib. Although this regimen initially led to marked improvement, subsequent further progression (Figure 1) prompted radical excision of the affected areas on the mons pubis and inguinally under local anesthesia. Histological examination of the inflammatory nodules revealed comedones and epidermal cysts with a peripheral chronic inflammatory reaction, showing histomorphologic changes consistent with those observed in cystic acne inversa (Figure 2). Vemurafenib was continued at a