CPC11: Bromoderma in a patient with chronic obstructive pulmonary disease

Xavier Peer, Ahmed Zwain, Marina Subnikova and Saleem Taibjee

Dorset County Hospital, Dorchester, UK

Bromoderma is a rare skin disorder that occurs after exposure to drugs containing bromine. As in other forms of halogenoderma, it can present with a wide range of cutaneous clinical features, including acneiform eruptions, neutrophilic dermatoses and vasculitis [Patterson W. Halogenodermas. In: Weedon’s Skin Pathology (Patterson W, ed.), 5th edn. London: Elsevier Health Sciences, 2021; 633]. Proposed mechanisms include halogen ions acting as haptens triggering a delayed hypersensitivity reaction, drug excretion in sweat or sebum resulting in an inflammatory reaction or alterations in the pathogenicity of skin commensal microorganisms. Here we describe a case of bromoderma in a 79-year-old man to highlight a striking cutaneous morphology mimicking malignancy, and the importance of taking a detailed drug history, including inhaled medications. Our patient presented with a rapidly progressing vegetative purplish nodular plaque on his left medial thigh with further lesions in the right groin, left axilla and right antecubital fossa. His past medical history included chronic obstructive pulmonary disease, chronic kidney disease and type 2 diabetes mellitus. His medications were oral metformin and furosemide, in addition to salbutamol and Trimbow (beclomethasone dipropionate, formoterol, glycopyrronium bromide) inhalers, which he had been taking for roughly a year. The clinical diagnosis was rather uncertain, but cutaneous T-cell lymphoma (CTCL) such as mycosis fungoides was considered. Skin biopsy showed bland epidermal and infundibular hyperplasia with associated spongiosis, intraepidermal microabscesses and a dense superficial perivascular and interface infiltrate including lymphocytes, histiocytes and eosinophils. The histological differential diagnosis included pemphigus vegetans, hypertrophic lichen planus, CTCL and halogenoderma. Direct immunofluorescence was negative with no evidence of clonality on T-cell receptor gene rearrangement studies. After noting that his medications included a glycopyrronium bromide-containing inhaler, this was discontinued with subsequent rapid resolution of the lesions in the following 4 days. This case highlights the importance of considering inhaled medications in any case of a possible cutaneous drug reaction. To our knowledge this is the first reported case of glycopyrronium bromide inducing bromoderma.