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Author's personal copy Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, e9ee10
CASE REPORT
Cicatricial ectropion: A complication of topical 5-fluorouracil Dariush Nikkhah*, Ahid Abood, David Watt Bradford Royal Infirmary, Department of Plastic and Reconstructive Surgery, Duckworth Lane, Bradford, UK Received 1 August 2011; accepted 4 August 2011
KEYWORDS Cicatricial ectropion; Basal cell carcinoma; 5-fluorouracil
Summary Topical 5-fluorouracil (5-FU) is a simple chemotherapeutic treatment that can be used by the plastic surgeon for indicated skin lesions. We present a case of transient, cicatricial ectropion developing secondarily to topical treatment with 5-FU, and propose an algorithm for the management of this significant complication. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction
Case report
Topical 5-fluorouracil (5-FU) is an inexpensive and simple chemotherapeutic treatment that can be used by the plastic surgeon for indicated skin lesions. It is applied to the affected area twice daily and may be applied for up to six weeks or more. An effective response to treatment is frequently indicated by a marked inflammatory reaction that usually subsides upon discontinuation. We present a case of transient, cicatricial ectropion developing secondarily to topical treatment with 5-FU, and propose an algorithm for the management of this rare but significant complication (Figure 1).
An 83-year-old gentleman was referred from dermatology to the plastic surgery department for excision biopsy of a probable basal cell carcinoma (BCC) in the left postauricular sulcus. His initial presentation to dermatology was for consideration of the management of this lesion along with actinic keratoses on his face. These were located approximately 1 cm lateral to the right lateral canthus and over the left malar region. The patient was referred to the plastic surgery department for excision of the former lesion (BCC), and topical 5-FU was prescribed by the dermatologists for the actinic keratoses. Approximately one month following this referral the gentleman arrived in the plastic surgery out-patient department. It was noted that he had a significant ectropion affecting the right eye and marked lid retraction on the left side (Figure 2). These were new findings that coincided with the widespread application of
* Corresponding author. Tel. þ44 7747096896. E-mail address:
[email protected] (D. Nikkhah).
1748-6815/$ - see front matterª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.012
Author's personal copy e10
D. Nikkhah et al.
Proposed Algorithm for management of lower lid distortion secondary to 5-FU Presence of Lower lid distortion (Ectropion or lid retraction) Yes Presence of secondary changes
5-FU to the face. The BCC in the left post-auricular sulcus had completely resolved. The 5-FU was discontinued and the patient was added to the waiting list for surgical correction of the lower lid deformities in order to prevent worsening of secondary changes that had already started to develop (palpebral conjunctival hypertrophy). The patient attended for surgery 2 weeks later, both lower lid deformities had spontaneously resolved.
(Blepharitis, palpebral conjunctival hypertrophy and keratinization, conjunctival scarring)
Yes
Discussion
No
Discontinue 5-FU
Discontinue 5-FU
Close observation & consider early
Close observation
surgical intervention.
Figure 1 Proposed Algorithm for management of lower lid distortion secondary to 5-FU.
The development of ectropion following systemic 5-FU appears to be more frequently reported than with its topical application.1e4 Although this complication is rare, it can result in significant secondary changes that include blepharitis, palpebral conjunctival hypertrophy, keratinization and conjunctival scarring. Permanence following discontinuation of topical 5-FU has not been described, however the approach of ‘benign neglect’ may not be appropriate in all cases due to the development of secondary changes. A cautious approach, ensuring that the patient is adequately educated with respect to the use of 5-FU is stressed. The potential to cause significant lid distortion should not be underestimated.
Conflict of interest/Funding All named authors hereby declare that they have no conflicts of interest to disclose. This research received no specific grant from any funding agency in the public, commercial or not-for profit services.
References
Figure 2 Photograph demonstrating an ectropion of the right lower lid and marked lid retraction on the left side.
1. Straus DJ, Mausolf FA, Ellerby RA, McCracken JD. Cicatricial ectropion secondary to 5-fluorouracil therapy. Med Pediatr Oncol 1977;3:15e9. 2. Hurwitz BS. Cicatricial ectropion: a complication of systemic fluorouracil. Arch Ophthalmol 1993;111:1608e9. 3. Hecker D, Hacker SM, Ramos-Caro FA, Flowers FP. Temporary ectropion due to topical fluorouracil. Cutis 1994;53:137e8. 4. Galentine P, Sloas H, Hargett N, Cupples HP. Bilateral cicatricial ectropion following topical administration of 5-fluorouracil. Ann Ophthalmol 1981;13:575e7.
