From the Guidelines
Skin changes in Chronic Lymphocytic Leukemia (CLL) are a significant concern, and patients should be managed with a comprehensive approach to prevent and treat these changes, prioritizing morbidity, mortality, and quality of life. Patients with CLL often develop bacterial skin infections due to compromised immunity, which should be treated promptly with appropriate antibiotics like cephalexin 500mg four times daily for 7-10 days 1. Easy bruising and petechiae occur from decreased platelet counts, requiring careful skin protection and avoidance of trauma. CLL-specific skin manifestations include leukemia cutis (infiltration of leukemic cells into the skin causing red-brown nodules), Sweet's syndrome (painful red plaques), and exaggerated reactions to insect bites. Some patients develop paraneoplastic pemphigus, a severe blistering condition requiring dermatological intervention with topical or systemic corticosteroids.
Key Considerations
- Sun sensitivity is common, especially in patients taking certain CLL medications like ibrutinib, necessitating sun protection with SPF 30+ sunscreen, protective clothing, and limited sun exposure 1.
- Regular skin examinations are essential as CLL patients have an increased risk of skin cancers, particularly squamous cell carcinoma.
- The management of skin changes in CLL should be guided by the most recent and highest quality evidence, with a focus on reducing morbidity, mortality, and improving quality of life.
Treatment Options
- Low-dose oral MTX (5–20 mg/week) and PUVA are effective therapies for reducing the number of skin lesions in patients with cosmetically disturbing lesions 1.
- Radiation therapy is a viable option for patients with solitary or localized skin lesions, with a total dose of 20 Gy recommended 1.
- Brentuximab vedotin (BV) should be considered in cases with multifocal skin lesions refractory to conventional therapies and in patients developing extracutaneous disease 1.
Prioritizing Patient Outcomes
The primary goal in managing skin changes in CLL is to prioritize patient outcomes, including morbidity, mortality, and quality of life, and to provide individualized care based on the most recent and highest quality evidence. By taking a comprehensive approach to preventing and treating skin changes, clinicians can improve patient outcomes and reduce the burden of CLL on patients' lives.
From the Research
Skin Changes with CLL
- Skin changes are a common occurrence in patients with Chronic Lymphocytic Leukemia (CLL) 2
- These changes can be diverse and include specific skin lesions, secondary skin tumors, and nonspecific skin changes 2
- Specific skin lesions can occur in about 25% of patients with CLL and can be associated with an unfavorable prognosis 2
- Secondary skin tumors are also more common in patients with CLL, with a risk of skin cancer that is eight times higher than in the healthy population 2
- Nonspecific skin changes can occur in 30-50% of patients with CLL and can include infectious skin changes, increased reactions to insect bites, and generalized itching 2
Dermatological Adverse Events with BTKi Treatment
- Dermatological adverse events (AEs) are generally mild during therapy with Bruton's tyrosine kinase inhibitor (BTKi) 3
- However, severe dermatological AEs can occur, including necrotizing vasculitis and fungal infections, which may require discontinuation of BTKi treatment 3
- Clinicians should pay attention to atypical rashes during BTKi treatment and skin biopsies are necessary for further diagnosis and intervention 3
Cutaneous Manifestations of CLL
- CLL can have many dermatologic implications, including leukemia cutis, eosinophilic dermatosis of hematologic malignancy, and a heightened risk of skin infections 4
- CLL patients are at an increased risk of secondary malignancies, most commonly of the skin 4
- Treatments for CLL can also have cutaneous implications, which should be considered in the interdisciplinary management of CLL patients 4