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he was on oral vandetanib therapy &#40;300&#8239;mg&#47;d&#41; for 15 days&#46; He denied taking any medication except vandatanib&#46; Few hours prior to the development of the rash&#44; he had been exposed to sunlight for a long time without sun protection&#46; Phototesting and biopsy were not performed&#46; Since the distribution of the eruption was strictly restricted to sun-exposed areas and vandetanib was the only medication&#44; this condition was assumed as a &#8220;vandetanib-induced phototoxic reaction&#8221;&#46; Vandetanib treatment was stopped&#46; Oral prednisolone 1&#8239;mg&#47;kg&#47;day was administered&#46; In a few days&#44; lesions progressed to proximal extremities&#44; back&#44; and chest with the involvement of 30&#37; of body surface area &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Oral mucosal erosions and conjunctivitis were observed&#46; Laboratory examination revealed elevated erythrocyte sedimentation rate &#40;65&#8239;mm&#47;h&#41; and white blood cells &#40;13&#46;800 mm<span class="elsevierStyleSup">3</span>&#41;&#46; Nikolsky&#39;s sign was positive&#46; A biopsy was performed and epidermal necrosis&#44; diffuse keratinocyte apoptosis in the basal layer&#44; and subepidermal separation were observed&#46; Due to having apoptotic kerotinocytes and interface tissue pattern which leads to subepidermal separation&#44; our case is regarded as a phototoxic reaction leading to TEN with almost full-thickness epidermal necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; He was managed with intravenous fluids&#44; prednisolone 1&#46;5&#8239;mg&#47;kg&#47;day&#44; prophylactic antibiotic&#44; and wet compresses&#46; During follow-up&#44; IVIg was initiated at a dose of 3&#8239;g&#47;kg&#46; In a few weeks&#44; with the improvement of cutaneous eruption and hemodynamic stabilization&#44; prednisolone dose was tapered gradually and the patient was discharged&#46; Cutaneous reactions are one of the most prevalent adverse events reported with vandetanib therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Sun exposure has been described as a common triggering factor for cutaneous reactions with vandetanib&#46; In literature&#44; there are few cases of vandetanib-induced photosensitivity reactions including phototoxicity&#44; photoallergic reactions&#44; pigmentation&#44; and SJS&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> In the present case&#44; a cutaneous photosensitive reaction was observed&#46; Although our patient did not undergo phototesting&#44; at the beginning symmetrical distribution of the lesions&#44; location only in the sun-exposed areas&#44; appearing immediately after sun exposure led us to diagnose this as a phototoxic reaction&#46; However&#44; in a couple of days lesions progressed to sun-protected areas&#44; with the development of widespread bullous lesions&#46; Our case represents a beginning as a phototoxic reaction induced by vandetanib and then progress to a life-threatening condition&#44; TEN&#44; and only controlled with IVIg&#46; In conclusion&#44; vandetanib can cause various cutaneous side effects from mild&#44; self-limited eruption to severe reactions&#44; which most of them are related to photosensitivity&#46; For that reason&#44; patients should be informed about photoprotection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0010" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0015" class="elsevierStylePara elsevierViewall">Busra Demirbag Gul&#58; Collected the data&#59; contributed the data or analysis tools&#59; wrote the paper&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nilgun Senturk&#58; Collected the data&#59; contributed the data or analysis tools&#59; wrote the paper&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Deniz Baycelebi&#58; Collected the data&#59; wrote the paper&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Levent Yildiz&#58; Collected the data&#59; wrote the paper&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Vandetanib induced phototoxic reaction progressed to toxic epidermal necrolysis
Busra Demirbag Gula,
Corresponding author
busrademirbag@windowslive.com

Corresponding author.
, Nilgun Senturka, Deniz Baycelebib, Levent Yildizb
a Department of Dermatology, Ondokuz Mayıs University, Faculty of Medicine, Samsun, Turkey
b Department of Pathology, Ondokuz Mayıs University, Faculty of Medicine, Samsun, Turkey
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he was on oral vandetanib therapy &#40;300&#8239;mg&#47;d&#41; for 15 days&#46; He denied taking any medication except vandatanib&#46; Few hours prior to the development of the rash&#44; he had been exposed to sunlight for a long time without sun protection&#46; Phototesting and biopsy were not performed&#46; Since the distribution of the eruption was strictly restricted to sun-exposed areas and vandetanib was the only medication&#44; this condition was assumed as a &#8220;vandetanib-induced phototoxic reaction&#8221;&#46; Vandetanib treatment was stopped&#46; Oral prednisolone 1&#8239;mg&#47;kg&#47;day was administered&#46; In a few days&#44; lesions progressed to proximal extremities&#44; back&#44; and chest with the involvement of 30&#37; of body surface area &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Oral mucosal erosions and conjunctivitis were observed&#46; Laboratory examination revealed elevated erythrocyte sedimentation rate &#40;65&#8239;mm&#47;h&#41; and white blood cells &#40;13&#46;800 mm<span class="elsevierStyleSup">3</span>&#41;&#46; Nikolsky&#39;s sign was positive&#46; A biopsy was performed and epidermal necrosis&#44; diffuse keratinocyte apoptosis in the basal layer&#44; and subepidermal separation were observed&#46; Due to having apoptotic kerotinocytes and interface tissue pattern which leads to subepidermal separation&#44; our case is regarded as a phototoxic reaction leading to TEN with almost full-thickness epidermal necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; He was managed with intravenous fluids&#44; prednisolone 1&#46;5&#8239;mg&#47;kg&#47;day&#44; prophylactic antibiotic&#44; and wet compresses&#46; During follow-up&#44; IVIg was initiated at a dose of 3&#8239;g&#47;kg&#46; In a few weeks&#44; with the improvement of cutaneous eruption and hemodynamic stabilization&#44; prednisolone dose was tapered gradually and the patient was discharged&#46; Cutaneous reactions are one of the most prevalent adverse events reported with vandetanib therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Sun exposure has been described as a common triggering factor for cutaneous reactions with vandetanib&#46; In literature&#44; there are few cases of vandetanib-induced photosensitivity reactions including phototoxicity&#44; photoallergic reactions&#44; pigmentation&#44; and SJS&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> In the present case&#44; a cutaneous photosensitive reaction was observed&#46; Although our patient did not undergo phototesting&#44; at the beginning symmetrical distribution of the lesions&#44; location only in the sun-exposed areas&#44; appearing immediately after sun exposure led us to diagnose this as a phototoxic reaction&#46; However&#44; in a couple of days lesions progressed to sun-protected areas&#44; with the development of widespread bullous lesions&#46; Our case represents a beginning as a phototoxic reaction induced by vandetanib and then progress to a life-threatening condition&#44; TEN&#44; and only controlled with IVIg&#46; In conclusion&#44; vandetanib can cause various cutaneous side effects from mild&#44; self-limited eruption to severe reactions&#44; which most of them are related to photosensitivity&#46; For that reason&#44; patients should be informed about photoprotection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0010" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0015" class="elsevierStylePara elsevierViewall">Busra Demirbag Gul&#58; Collected the data&#59; contributed the data or analysis tools&#59; wrote the paper&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nilgun Senturk&#58; Collected the data&#59; contributed the data or analysis tools&#59; wrote the paper&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Deniz Baycelebi&#58; Collected the data&#59; wrote the paper&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Levent Yildiz&#58; Collected the data&#59; wrote the paper&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 03650596
Original language: English
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