Acral Erythema: Graft-vs-Host Disease or Toxicoderma?

To the Editor.—  Recently, Crider et al¹ described eight patients who have received bone marrow transplants who developed the so-called chemotherapy-induced acral erythema, described by Burgdorf et al² and later by Levine et al.³ The differential diagnosis of palmoplantar erythemas is a difficult and common clinical problem, especially in patients who have received bone marrow transplants. In this situation, a great number of factors are implicated: graft-vs-host disease (GVHD), chemotherapy and other drug reactions, irradiation, and blood transfusions. Usually serial skin biopsies are necessary to prove the causative diagnosis.Chemotherapy-induced acral erythema involves palmar surfaces and the dorsa of the fingers and soles, but several patients have concomitant lesions on the scalp, neck, and chest.³ Graft-vs-host disease can frequently affect palms and soles, sometimes as a first and predominant sign of the disease.Although the histopathologic changes are not specific for GVHD, they are rather characteristic.