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Top 10 Software Testing Templates with Samples and Examples

Neha Parmar

Software testing ensures that a software product complies with all criteria and incorporates all functions sought from it, and is error-free. Using human or automated methodologies entails thoroughly assessing software/system components to gauge required features. The goal is to ensure the software meets the necessary quality standards and performs as planned.

A software testing template provides an established structure for planning and recording this important testing process. Sections include test goals, its scope, environment, strategy, and cases. SlideTeam’s content-ready template directs testers in the systematic design, execution, and evaluation of tests, assists them in finding flaws and assesses the software’s compliance with specification. A software testing template encourages consistency, speed, and efficient team communication. It offers a standardized method to do so, ultimately improving product quality and client satisfaction.

The software will run reliably, securely, and optimally thanks to thorough testing, resulting in time savings, increased financial efficiency, and more customer satisfaction. By discovering and fixing problems early in the development process, software testing plays a crucial role in guaranteeing the delivery of a dependable and effective solution that fulfills end-user expectations. The ultimate goal of a phenomenal end-user experience is also achieved.

Executing appropriate testing tools like a template, however, is a time- and labor- intensive aspect of creating software, a crucial step. SlideTeam offers a solution with its software testing templates. These customizable templates streamline the testing process and provide the necessary context, saving time and energy.

What’s even better, each of these templates is 100% customizable and editable. The content-ready nature provides you with the structure and a starting point; the editability feature ensures that you can customize the template according to audience profile.

Let’s explore these clutter-free solutions to software testing that makes life easy for all stakeholders.

Template 1 Software testing approach PPT template bundles

This PPT template covers methods, procedures, and outcomes of the testing process. These templates offer a coherent and well-organized structure with a polished and aesthetically pleasing appearance to represent your testing methodology effectively. Using these valuable tools may save time and improve the impact of your presentations. The complete deck in 20 slides is perfect for starting and maintaining professional conversations and ensures a comprehensive and well-structured solution to the testing part of software development. The processes of vulnerability assessment, functional testing and software testing approaches and strategies are covered as well. This compendium is a one-stop solution.

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Template 2 :- Software Testing for Effective Project Implementation DK MD

Use this thorough deck of 18 slides, designed for expert discussion sessions to communicate your thoughts and vision. With its range of slides that are all thematically related, this presentation template guarantees a well-structured experience for your clients. Testing is significant in project execution, risk mitigation, improving user experience, and guaranteeing a stable and high quality software system by carefully assessing software functionality, performance, and dependability. Downloading this template will give your professional service an edge.

Template 3:- Software Testing PPT Template Bundles 

Start working together and convey your messages clearly with this superb PPT Template. You have the ideal resource to give a thorough explanation of the subject, thanks to the 10 professionally created slides in this PowerPoint slideshow. Use it to start with types of information, such as statistics, facts, data charts, before moving on to the moot point of software testing. Don’t let this opportunity to gather comprehensive and useful presentation material go abegging.

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Template 4:- Software Testing Life Cycle In Product Quality Assurance 

Use this PPT template to make the most of your presentations. It contains valuable information on requirement gathering, test planning, development testing, test execution, and reporting. You can download this template immediately to improve your presentations and get the most out of them. It comes with a series of slides that emphasize the five key steps in the testing process.

Template 5:- Software Testing Waterfall Model

This PPT Template demonstrates a step-by-step, linear method of software testing. It includes requirements analysis, test planning, test case development, test execution, and test closure and moving through each process with discipline. A systematic and well- defined testing procedure requires finishing each step before going on to the next. The Waterfall Model offers a distinct and structured framework for testing, making monitoring development and spotting problems at each level simpler.

Template 6:- Risk Analysis In Software Testing PPT Ideas

Use this powerful presentation template for software testing to include risk analysis in your bag of tricks for software testing. Risk analysis assists in identifying possible hazards, prioritizing these according to their significance and likelihood, and developing effective management or mitigation measures. Including risk analysis concepts in your presentation demonstrates a proactive commitment to reducing project risks and guaranteeing a more effective and successful software testing process. This benefits all stakeholders.

Template 7 Five Key Challenges Of User Acceptance Software Testing

These content-ready PowerPoint bundle has five key challenges that software testing must take head-on. First, it might be challenging to match customer expectations with the features and functionalities of the product. Second, providing enough test coverage that considers user scenarios is critical. Thirdly, it might not be easy to coordinate and include users in the testing process. Fourth, handling and resolving conflicting user requests and input might be complex. Finally, measuring and evaluating user acceptance and satisfaction might be complex and subjective. Download this presentation template now to assist your investors.

Template 8 Feature List Of Automation Tools For Software Testing

This PowerPoint Template covers essential features of Automation tools. Software testing automation tools provide capabilities, including test script management, execution, and authoring. They allow testers to conduct tests across platforms, automate processes, and interface with development frameworks. These programs include performance testing features, cross-browser and mobile testing assistance, and reporting capabilities. They speed up testing procedures, save time, and raise the caliber of software.

Template 9:- Manual Software Testing Process With Defect Logging

This presentation template will assist you in providing a concise and persuasive summary of a systematic procedure to guarantee software quality. Manually performing test cases allows testers to look for errors and abnormalities. As testers methodically record and report detected faults, defect tracking is crucial to this procedure. It entails gathering pertinent data, such as instructions for duplicating errors and anticipated and actual outcomes. The software quality improves when defects are tracked, prioritized, and fixed.

Template 10:- End-to-end QA and Testing DevOps IT Determine Software Testing Initiatives DevOps

Determining the performance of software testing programs depends critically on end-to- end Quality Assurance (QA) and testing in DevOps. Businesses can guarantee ongoing quality improvement with the inclusion of QA and testing throughout the DevOps lifecycle. It also entails establishing reliable test environments, automating testing procedures, and creating effective feedback loops. End-to-end QA and testing in DevOps facilitate quicker, more reliable releases, encourage teamwork, and ultimately improve software quality and customer satisfaction.

TESTING IS GOOD

In conclusion, SlideTeam's software testing templates streamline the testing procedure by offering configurable solutions that reduce time and effort. These templates facilitate testing by providing the required context and facilitating practical software evaluation. Software testing templates help developers improve their testing processes and ensure that problems are found and fixed accurately and thoroughly throughout the development cycle.

FAQs on Software Testing

What is in software testing.

Software testing is a critical procedure to assess and validate software systems to guarantee performance, dependability, and quality. It entails running test cases, looking for flaws or problems, and ensuring the program complies with all requirements. Functional testing, performance testing, security testing, and usability testing, among other forms, are all carried out. Test planning, test case design, test execution, and defect tracking also happen. The aim is to find flaws, raise software quality, raise user satisfaction, and lower risks. Software testing, ultimately, contributes to the delivery of dependable and high-quality software solutions to satisfy, or even exceed, customer expectations.

What are the four main types of software testing?

Functional testing verifies that the software operates as intended and satisfies user equirements. It guarantees that features and services operate, as expected. Performance testing: Performance testing measures how well and responsively the program performs under varied loads and stresses. It pinpoints performance bottlenecks, gauges reaction times, and rates the system's scalability. Security testing evaluates a program's capacity to safeguard data, uphold confidentiality, and thwart unauthorized access. It finds weaknesses, evaluates authentication and authorization processes, and confirms adherence to security norms. Usability testing: Usability testing looks at the software's usability and user-friendliness. It assesses the interface, navigation, and overall user experience to ensure the program satisfies user expectations.

What is a software testing job?

Software testing is a professional task of verifying the dependability and quality of software systems. Program testers are responsible for creating and carrying out test cases, locating flaws or problems, and confirming that the program satisfies required specifications. They carry out forms of testing, examine test outcomes, and alert the development team to any problems. Additionally, they participate in the software development lifecycle and work with stakeholders to comprehend project requirements and design test strategies. Strong analytical and problem-solving abilities, meticulousness, and familiarity with testing procedures and tools are necessary job skills.

What is a software test called?

A software test, often referred to as a test case, is a particular set of requirements, inputs, and anticipated results used to verify the operation and behavior of a software system. Test cases offer an organized way to run tests, find flaws, and guarantee the accuracy and dependability of the product.

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Software testing might not be the sexiest part of coding, but that doesn't mean it lacks intrigue or importance. After all, who wants to use a buggy app? It's software testing that ensures smooth operation and prevents annoying glitches from making it into the final product. Without it, our lives would be an endless cycle of frustratedly bashing at buttons and kicking our computers in frustration. Good testers have an eye for detail and can think as critically as a detective looking for clues - although hopefully with less mystery and suspense!

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Software Testing PowerPoint Templates & Slides

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Software Testing PowerPoint Templates for Presentations:

The Software Testing PowerPoint templates go beyond traditional static slides to make your professional presentations stand out. Given the sleek design and customized features, they can be used as PowerPoint as well as Google Slides templates . Inculcated with visually appealing unique and creative designs, the templates will double your presentation value in front of your audience. You can browse through a vast library of Software Testing Google Slides templates, PowerPoint themes and backgrounds to stand out in your next presentation.

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What is a software testing powerpoint template.

A Software Testing PowerPoint template is a ready-made presentation template that provides a structured framework for creating professional Software Testing presentations. The Software Testing PPT presentation template includes design elements, layouts, and fonts that you can customize to fit your content and brand.

How To Choose The Best Software Testing Presentation Templates?

Keep the following points in mind while choosing a Software Testing Presentation template for PowerPoint (PPT) or Google Slides:

• Understand your presentation goals and objectives.
• Make sure the Software Testing template aligns with your visual needs and appeal.
• Ensure the template is versatile enough to adapt to various types of content.
• Ensure the template is easily customizable.

Are Software Testing PowerPoint Templates Compatible with Google Slides?

Yes, all our Software Testing presentation templates are compatible and can be used as Software Testing Google Slides templates.

What Are the Advantages of Software Testing Presentation Templates?

Software Testing PPT presentation templates can be beneficial because they:

• Add multiple visual and aesthetic layers to your slides.
• Ensure that complex information, insights and data is presented in a simplistic way.
• Enhance the overall visual appeal of the content.
• Save you a lot of time as you don’t have to start editing from scratch.
• Improve the professional outlook of your presentation.

Can I Edit The Elements In Software Testing PowerPoint Templates?

Yes, our Software Testing PowerPoint and Google Slides templates are fully editable. You can easily modify the individual elements including icons, fonts, colors, etc. while making your presentations using professional PowerPoint templates .

How to Download Software Testing PowerPoint Templates for presentations?

To download Software Testing presentation templates, you can follow these steps:

• Select the resolution (16*9 or 4*3).
• Select the format you want to download the Software Testing template in (Google Slides or PowerPoint).
• Make the payment (SlideUpLift has a collection of paid as well as free Software Testing PowerPoint templates).
• You can download the file or open it in Google Slides.

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Ph.D. Defense Presentation by Carl Hildebrandt

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Autonomous System Testing: Incorporating Physical Environments and Physical Semantics

Abstract : 

As the integration of autonomous systems becomes increasingly common in our everyday lives, their shortcomings and failures become more apparent. Therefore, rigorous validation to ensure their safety and reliability is paramount. Since autonomous systems behavior is predominantly driven by software, and software validation has achieved significant success in validating applications billions of people use today, it seems natural to attempt to apply current software validation to autonomous systems. Such application, however, requires overcoming two key challenges introduced by the differences between traditional software and autonomous systems, namely the physical environment and the systems physical semantics. Without considering these differences, traditional software testing techniques struggle to cope with a large unbounded input space and to effectively target areas of the software that drive the behaviors of the autonomous system. This work introduces techniques grounded in traditional software analysis that overcome these challenges spanning the entire testing pipeline: test generation, test execution, and test adequacy assessment.

In the area of Test Generation, I investigated techniques to produce tests based on a vehicle's kinematics to ensure they aligned with the physical semantics of the autonomous system, all while using parametrizable scoring models to identify tests that stress an autonomous system. Moreover, I leveraged a vast array of existing sensor data from real-world physical environments to identify performance discrepancies across different versions of an autonomous system. The sensor data that yielded discrepancies were then compared against the autonomous systems Operational Design Domain to determine their relevance.

In Test Execution, I have devised a mixed-reality strategy that bridges the gap between simulation and real-world testing. Recognizing that real-world testing, while ideal, is often impractical, hazardous, and expensive, my approach integrates virtual elements into real physical environments. This allows for validating performance and safety while reducing both cost and time. Additionally, I designed a haptic suit for drones, enabling us to test the physical semantics of a drone by applying forces to the drone in the real world.

Regarding Test Coverage, I created Physical Coverage, one of the first coverage metrics for autonomous systems, which considers both the physical environment and physical semantics of the autonomous system. Utilizing physical reachability analysis and geometric vectorization, this metric offers a quantifiable measure of test suite effectiveness. It has proven instrumental in identifying missing scenarios and redundant tests in datasets such as Waymo's Open Perception dataset.

By addressing these challenges across the entire testing pipeline, this dissertation takes a significant step toward creating safer and more reliable autonomous systems.  

Committee :  

• Matthew Dwyer, Committee Chair   (CS/SEAS/UVA)
• Sebastian Elbaum, Advisor (CS/SEAS/UVA)
• Seongkook Heo, (CS/SEAS/UVA)
• Nicola Bezzo (ESE,ECE/SEAS/UVA)
• Borislava Simidchieva (BBN, Raytheon) 

Retrace your steps with Recall

Search across time to find the content you need. Then, re-engage with it. With Recall, you have an explorable timeline of your PC’s past. Just describe how you remember it and Recall will retrieve the moment you saw it. Any photo, link, or message can be a fresh point to continue from. As you use your PC, Recall takes snapshots of your screen. Snapshots are taken every five seconds while content on the screen is different from the previous snapshot. Your snapshots are then locally stored and locally analyzed on your PC. Recall’s analysis allows you to search for content, including both images and text, using natural language. Trying to remember the name of the Korean restaurant your friend Alice mentioned? Just ask Recall and it retrieves both text and visual matches for your search, automatically sorted by how closely the results match your search. Recall can even take you back to the exact location of the item you saw.

Note:  Recall is optimized for select languages (English, Chinese (simplified), French, German, Japanese, and Spanish. Content-based and storage limitations apply. For more information, see https://aka.ms/nextgenaipcs .

System requirements for Recall

Your PC needs the following minimum system requirements for Recall:

A Copilot+ PC

8 logical processors

256 GB storage capacity

To enable Recall, you’ll need at least 50 GB of storage space free

Saving screenshots automatically pauses once the device has less than 25 GB of storage space

How to use Recall

To open Recall, use the keyboard shortcut Windows logo key   +J , or select the following Recall icon on your taskbar:

Your timeline in Recall is broken up into segments, which are the blocks of time that Recall was taking snapshots while you were using your PC. You can hover over your timeline to review your activity in a preview window. Selecting the location on the timeline or selecting the preview window loads the snapshot where you can  interact with the content .

Search with Recall

Maybe you wanted to make that pizza recipe you saw earlier today but you don’t remember where you saw it. Typing goat cheese pizza into the search box would easily find the recipe again. You could also search for pizza or cheese if you didn’t remember the specific type of pizza or cheese. Less specific searches are likely to bring up more matches though. If you prefer to search using your voice, you can select the microphone then speak your search query.  

By default, results are shown from all apps where Recall found matches. You can narrow down your results by filtering the matches to a specific app by selecting an app from the list.

When the results are displayed, they will be listed under the headings of text matches and visual matches . Matches that are closer to your search are shown first. You’ll also notice that some items are listed as one of the following types of matches:

Close match : Close matches typically include at least one of the search terms or images that are representative of a term in your query.

Related match : Matches that share a commonality with the search terms would be considered related. For instance, if you searched for goat cheese pizza , you might also get related matches that include lasagna or cannelloni since they are Italian dishes too.

Interacting with content

Once you’ve found the item you want to see again, select the tile. Recall opens the snapshot and enables screenray, which runs on top of the saved snapshot. Screenray analyzes what’s in the snapshot and allows you to interact with individual elements in the snapshot. You’ll notice that when screenray is active, your cursor is blue and white. The cursor also changes shape depending on the type of element beneath it. What you can do with each element changes based on what kind of content screenray detects. If you select a picture in the snapshot, you can copy, edit with your default .jpeg app such as Photos , or send it to another app like the Snipping Tool or Paint . When you highlight text with screenray, you can open it in a text editor or copy it. For example, you might want to copy the text of a recipe’s ingredients list to convert it to metric.

Note:  When you use an option that sends snapshot content to an app, screenray creates a temporary file in C:\Users\[username]\AppData\Local\Temp in order to share the content. The temporary file is deleted once the content is transferred over the app you selected to use.

Below your selected snapshot, you have more snapshot options. In many cases, you can have Recall take you back to exact location of the item, such as reopening the webpage, PowerPoint presentation, or app that was running at the time the snapshot was taken. You can also hide screenray, copy the snapshot, delete the snapshot, or select … for more snapshot options.

Pause or resume snapshots

To pause recall, select the Recall icon in the system tray then Pause until tomorrow .  Snapshots will be paused until they automatically resume at 12:00 AM. When snapshots are paused, the Recall system tray icon has a slash through it so you can easily tell if snapshots are enabled. To manually resume snapshots, select the Recall icon in the system tray and then select Resume snapshots .  You can also access the Recall & snapshots settings page from the bottom of this window.

What if I don’t want Recall to save information from certain websites or apps?

You are in control with Recall. You can select which apps and websites you want to exclude, such as banking apps and websites.  You’ll need to use a supported browser for Recall to filter websites and to automatically filter private browsing activity. Supported browsers, and their capabilities include:

Microsoft Edge: blocks websites and filters private browsing activity

Firefox: blocks websites and filters private browsing activity

Opera:  blocks websites and filters private browsing activity

Google Chrome: blocks websites and filters private browsing activity

Chromium based browsers:  For Chromium-based browsers not listed above, filters private browsing activity only, doesn’t block specific websites

To exclude a website:

Select … then Settings to open the Recall & snapshots settings page.

You can also go to Windows Settings > Privacy & Security > Recall & Snapshots to manage Recall.

Select Add website for the Websites to filter setting.

Type the website you want to filter into the text box. Select Add to add it to the websites to filter list.

To exclude an app:

Select … then Settings to open the Recall & snapshots settings page

Select Add app  for the Apps to filter setting.

From the app list, select the app you want to filter from Recall snapshots.

In two specific scenarios, Recall will capture snapshots that include InPrivate windows, blocked apps, and blocked websites. If Recall gets launched, or the Now option is selected in Recall, then a snapshot is taken even when InPrivate windows, blocked apps, and blocked websites are displayed. However, these snapshots are not saved by Recall. If you choose to send the information from this snapshot to another app, a temp file will also be created in C:\Users\[username]\AppData\Local\Temp to share the content. The temporary file is deleted once the content is transferred over the app you selected to use.

Managing your Recall snapshots and disk space

You can configure how much disk space Recall is allowed to use to store snapshots. The amount of disk space you can allocate to Recall varies depending on how much storage your PC has. The following chart shows the storage space options for Recall:

You can change the amount of disk space used or delete snapshots from the Recall & snapshots settings page. 

To change the storage space limit:

1. Expand the Storage settings.

2. Change the Maximum storage for snapshots limit by choosing the limit from the drop-down list. When the limit is reached, the oldest snapshots are deleted first.

To delete snapshots:

Expand the Delete snapshots settings.

You can choose to delete all snapshots or snapshots withing a specific timeframe.

To delete all snapshots, select Delete all .

To delete snapshots from a specific timeframe, select a timeframe from the drop-down list, then select Delete   snapshots.

Keyboard shortcuts for Recall

You can use the following keyboard shortcuts in recall:, when interacting with a snapshot with screenray, you can use the following keyboard shortcuts:, microsoft’s commitment to responsible ai and privacy.

Microsoft has been working to advance AI responsibly since 2017, when we first defined our AI principles and later operationalized our approach through our Responsible AI Standard. Privacy and security are principles as we develop and deploy AI systems. We work to help our customers use our AI products responsibly, sharing our learnings, and building trust-based partnerships. For more about our responsible AI efforts, the  principles that guide us, and the tooling and capabilities we've created to assure that we develop AI technology responsibly, see Responsible AI .

Recall uses optical character recognition (OCR), local to the PC, to analyze snapshots and facilitate search. For more information about OCR, see Transparency note and use cases for OCR . For more information about privacy and security, see Privacy and security for Recall & screenray .

We want to hear from you!

If there's something you like, and especially if there's something you don't like, about Recall you can submit feedback to Microsoft by selecting … then the  Feedback icon  in Recall to submit feedback on any issues that you run into. 

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News & Insights

Aehr Test Systems Updates Corporate Presentation

May 29, 2024 — 08:51 am EDT

Written by TipRanks Newsdesk for TipRanks  ->

The latest update is out from Aehr Test Systems ( AEHR ).

Aehr Test Systems has released an updated corporate presentation on its website, which can be accessed through the “Investor Relations” section. This document is for informational purposes and not for official SEC filing or liability. It’s intended to be part of a broader set of communications and isn’t necessarily an indication of materiality. While there’s no commitment to update the information, the company reserves the right to do so as needed or as legally required.

For an in-depth examination of AEHR stock, go to TipRanks’ Stock Analysis page .

The views and opinions expressed herein are the views and opinions of the author and do not necessarily reflect those of Nasdaq, Inc.

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Onera Health to Present Latest Data on Patch-Based Home Sleep Test

May 30, 2024 | Home Apnea Testing | 0 |

Onera Health will present data on its Onera Sleep Test System through poster abstracts and scientific presentations at SLEEP 2024.

Summary: Onera Health will present the latest data on its patch-based Onera Sleep Test System (Onera STS) at the upcoming SLEEP 2024 conference in Houston. The company will showcase its home polysomnography solution through poster abstracts and scientific presentations, including two late-breaking abstracts. During the conference, Onera will also demonstrate its full-service clinical-grade PSG-as-a-Service solution to physicians, providing insights into setting up home polysomnography programs.

Key Takeaways:

• Onera Health will present new data on the Onera STS through poster abstracts and scientific presentations at SLEEP 2024.
• The company’s presentations will highlight the effectiveness and user experience of the Onera STS for home-based sleep studies.
• Onera will engage with physicians, researchers, and technicians at SLEEP 2024, showcasing its clinical-grade PSG-as-a-Service solution and discussing the implementation of home polysomnography programs.

Onera Health announced it will present the latest data on its patch-based Onera Sleep Test System (Onera STS) in poster abstracts and scientific presentations at the upcoming SLEEP 2024 conference in Houston.

“SLEEP is the most important venue for meeting the sleep medicine community, and we look forward to presenting our home polysomnography solution to physicians, researchers, and technicians. We are excited to be in Houston not only to demonstrate our solution but also to be part of the scientific exchange at a time when sleep medicine is increasing in relevance for population health,” says Ruben de Francisco, founder and Chief Executive Officer of Onera Health, in a release.

During the conference, the company will showcase its full-service clinical-grade PSG-as-a-Service solution to physicians, who can learn more at the booth about setting up a home polysomnography program with Onera. Additionally, Onera STS will be featured in two poster presentations and two late-breaking abstracts, highlighting recent clinical study results from trials assessing the Onera STS and home polysomnography.

Presentation Details

Details of Onera’s abstract and poster sessions are as follows:

Late-Breaking Abstract featuring Onera STS:

• Abstract ID: LBA-1304
• Poster Presentation Date and Time: June 4, 11 am
• Poster Board Number: #404
• Abstract ID: LBA-1312
• Poster Board Number: #412
• Abstract ID: 1101
• Poster Board Number: #350
• Abstract ID: 1105
• Poster Board Number: #354

Photo caption: Onera Sleep Test System. The sensors of the patch-based Onera STS capture all signals required for a polysomnography. 

Photo credit: Business Wire

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• Case report
• Open access
• Published: 27 May 2024

A rare incidence of severe dermatological toxicities triggered by concomitant administration of all-trans retinoic acid and triazole antifungal in patients with acute promyelocytic leukemia: a case series and review of the literature

• Aisha Jamal   ORCID: orcid.org/0000-0001-5022-7498 1 , 3 ,
• Rafia Hassam 1 ,
• Qurratulain Rizvi 1 ,
• Ali Saleem 1 ,
• Anum Khalid 2 &
• Nida Anwar 1  

Journal of Medical Case Reports volume  18 , Article number:  261 ( 2024 ) Cite this article

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All-trans retinoic acid (ATRA) is an indispensable part of the treatment of acute promyelocytic leukemia (APL). Although, mild cutaneous toxicities like mucocutaneous xerosis, rash, and pruritus are well reported, ATRA associated severe dermatological toxicities are extremely rare. ATRA is primary metabolized by cytochrome P450 (CYP450) enzyme system, and triazole antifungals are notorious for their strong inhibitory effect on CYP450.

Case presentation

Three Asian APL patients experienced rare ATRA-induced severe dermatological toxicities: exfoliative dermatitis (ED) in cases 1 and 2, and necrotic scrotal ulceration in case 3. Both case 1 (33-year-old female), and case 2 (28-year-old male) landed in emergency department with dehydration, generalized skin erythema and xerosis during their induction chemotherapy. Both of these patients also developed invasive aspergillosis and required concomitant triazole antifungals during their chemotherapy. For ED, intravenous fluids and broad-spectrum antibiotics were started along with application of local emollients to prevent transdermal water loss. Although their general condition improved but skin exfoliation continued with complete desquamation of palms and soles. Dermatology was consulted, and clinical diagnosis of ED was established. Discontinuation of ATRA resulted in complete resolution of ED. Case 3 (15-year-old boy) reported two blackish mildly tender scrotal lesions during induction chemotherapy. He also had mucocutaneous candidiasis at presentation and was kept on triazole antifungal. Local bacterial & fungal cultures, and serological testing for herpes simplex virus were reported negative. Despite adequate local care and optimal antibiotic support, his lesions persisted, and improved only after temporary discontinuation of ATRA. After a thorough literature review and considering the temporal association of cutaneous toxicities with triazole antifungals, we speculate that the concomitant use of triazole antifungals inhibited the hepatic metabolism of ATRA, resulting in higher serum ATRA concentration, and markedly accentuated cutaneous toxicities in our patients.

By highlighting this crucial pharmacokinetic interaction, we want to caution the fellow oncologists to be mindful of the inhibitory effect of triazole antifungals on CYP450. We propose using a non-myelosuppressive combination of ATRA and arsenic trioxide for management of APL hence, obliterating the need of prophylactic antifungals. However, in the event of invasive fungal infection (IFI), we suggest using alternative class of antifungals.

Peer Review reports

Acute promyelocytic leukemia (APL) is a rare and potentially curable subtype of acute myeloid leukemia (AML), accounting for 5–8% of AML cases [ 1 ]. Genetically, APL is characterized by reciprocal translocation t(15:17) (q22;q11–12), with consequent fusion of promyelocytic (PML) gene on chromosome 15q22 to retinoic acid receptor-alpha (RAR-alpha) gene on chromosome 17q21. The resultant fusion oncoprotein, PML-RARA, induces transcriptional repression, chromatin condensation, maturation arrest, and accumulation of abnormal promyelocytes [ 2 ]. Advent of all-trans retinoic acid (ATRA) has revolutionized the treatment landscape of APL, and along with the backbone of anthracycline based chemotherapy, it is considered to be the standard of care for APL patients. Combination treatment with ATRA plus anthracycline based chemotherapy achieves an overall complete remission and cure rate of 95% and 80% respectively, rendering ATRA indispensable in the management of APL [ 3 ].

ATRA, an active metabolite of vitamin A, belongs to a class of retinoids. Although retinoids are well known for their dermatological side effects like xerosis, xerostomia, erythema, pruritis, and exfoliation; severe dermatological side effects of ATRA, especially in the dosage pertinent to APL (45 mg/m 2 ), are rare. So far, only a single case of exfoliative dermatitis (ED) and a few cases of scrotal ulceration have been reported in literature [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. We, here in, report a case series of three patients with serious and rare ATRA associated dermatological complications. We have also discussed upon the potentially precipitating pharmacokinetic interactions, as well as the detailed clinical course and management of our patients as simply withholding ATRA can jeopardize the outcome of this potentially curable malignant disorder.

In all three patients, ATRA was started as soon as abnormal promyelocytes were documented on peripheral smear/bone marrow aspirate examination (Figs.  1 , 2 , 3 ). Diagnosis was further confirmed through cytogenetic analysis as well as PML-RARA detection by polymerase chain reaction. Additionally, in all three patients, chemotherapeutic treatment was instituted according to European APL protocol, based on their risk-group classification.

Exfoliative dermatitis &Onychomadesis (CASE 1). a Peripheral smear. b Bone marrow aspirate. c Desquamation of soles. d Desquamation of palms. e Dry exfoliation of feet and shins. f Onychomadesis

Exfoliative dermatitis (CASE 2). a Peripheral smear. b Bone marrow aspirate. c and d Erythema and scaling of hands. e Cutaneous desquamation of soles

Scrotal lesions (CASE 3). a Peripheral smear. b Bone marrow aspirate. c and d Necrotic scrotal lesions with black eschar

Case 1: A 33-year-old Asian female presented in ER with history of fever, heavy menstrual bleeding and rash all over body. Induction chemotherapy and steroid prophylaxis was promptly started to prevent differentiation syndrome (DS). On Day-10 of induction chemotherapy, she developed high grade fever, cough and shortness of breath. High-resolution computerized tomography (HRCT) showed randomly scattered discrete nodular opacities with surrounding ground glass haze in both lung fields, suggestive of invasive fungal infection (IFI). Voriconazole was immediately started along with broad-spectrum antibiotics. She improved over the following 72 hour, and was discharged from hospital on Day-17. Subsequently, she landed in emergency department on Day-23 with severe dehydration, shivering, tachycardia, generalized skin erythema and discoloration of nail beds. Intravenous fluids and broad-spectrum antibiotics were started along with application of local emollients to prevent transdermal water loss. Over the next 24-36 hour, her general condition was stabilized however; skin exfoliation continued with complete desquamation of palms and soles (Fig.  1 ). Dermatology was consulted, and a clinical diagnosis of onychomadesis and exfoliative dermatitis (ED) was made. A review of her clinical case demonstrated no apparent cause for ED except for a rare association with ATRA. However, considering the curative potential of ATRA, it was continued till Day-28 as per protocol. Her skin condition gradually resolved over next 10–14 days after discontinuation of ATRA. She had recurrence of similar skin condition upon re-exposure to ATRA in her consolidation chemotherapeutic cycles, however, the exfoliation was mild and patchy that responded well to good oral hydration and local skin emollients.

Case 2: A 28-year-old Asian male presented in the out-patient clinic with the history of generalized weakness, high-grade-fever, productive cough and bruises over body. On examination, he had multiple ecchymosis and petechiae with coarse crepitations involving right-middle and left-lower lung fields. He was promptly started on broad-spectrum antibiotics. Additionally, as per protocol, induction chemotherapy and dexamethasone prophylaxis was also instituted. His fever and cough remained unresponsive despite broad-spectrum antibiotics. Voriconazole was instituted upon the identification of IFI on HRCT findings. By day-10, coagulopathy was normalized, and clearance of abnormal promyelocytes was documented by Day-18. On Day-20, he complained of skin dryness, itching and scaling; physical examination revealed generalized xerosis and erythema (Fig.  2 ). Despite aggressive skin care, generalized skin exfoliation, most pronounced on palms and soles, ensued. Clinical diagnosis of ED was established after obtaining dermatological consultation. However, in view of his clinical stability, ATRA was continued. Bone marrow aspirate on Day-28 showed morphological remission. Recurrence of erythema and exfoliation was documented during consolidation phase of chemotherapy, but the condition was responsive to local emollients and oral hydration.

Case 3: A 15-year-old Asian male presented in the out-patient clinic with complains of high-grade-fever, muco-cutaneous bleeding and pancytopenia. On presentation, patient was febrile and had oral thrush. After sending his baseline tests he was taken on broad-spectrum antibiotics and triazole antifungal (itraconazole). After completion of induction chemotherapy, patient was discharged with bi-weekly follow-ups.On Day15, he reported two blackish, mildly tender scrotal lesions with minimal serous discharge (Fig.  3 ). Antibiotic cover for soft tissue infection was commenced along with local wound care with topical steroids and antibiotics. He had no sign of systemic infection/sepsis. Local bacterial & fungal cultures and serological testing for herpes simplex virus were reported negative. Despite adequate local care and optimal antibiotic support, his lesions showed no sign of healing, and two new lesions were developed. Lesion biopsy for histopathological evaluation was declined by the patient. Keeping the rare but reported occurrence of ATRA-induced scrotal ulceration and fournier's gangrene; ATRA was transiently withheld for ten days and the lesions started to regress. However, considering the indispensable role of ATRA in APL, it was reinstituted. Scrotal lesions persisted without any worsening. ATRA was stopped after completion of protocol. Complete resolution of scrotal lesions was documented over the following two weeks. Afterwards, he received two cycles of consolidation chemotherapy, but no recurrence was reported.

Discussion and conclusion

The antineoplastic role of ATRA remains indispensable in the curative management of APL. It is considered a relatively safe drug with a well-known toxicity profile. Commonly reported adverse events include DS, pseudotumor-cerebri, hypertriglyceridemia, transaminitis, and headache. Although, mild cutaneous toxicities like muco-cutaneous xerosis, photosensitivity, rash, pruritus and sweet’s syndrome are well reported, severe dermatological toxicities are rarely reported in literature [ 18 , 19 ]. In this case series, we have discussed three cases of ATRA-induced rare dermatological complications in APL.

Case 1 and 2 developed ED during remission induction phase of chemotherapy. Literature review revealed only a single reported occurrence of ATRA-induced ED in APL by YonelIpek et al. [ 4 ]. ED is a potentially life-threatening cutaneous manifestation that is characterized by diffuse skin erythema and scaling. Various underlying disorders can trigger its onset through a complex interplay of inflammatory cytokines and phagocytes. In contrast to our cases, the case reported by Yonel Ipek et al. developed xerosis in consolidation phase, which akin to our cases started after two weeks of ATRA exposure and rapidly deteriorated to generalized erythroderma and scaling. In both cases, discontinuation of ATRA resulted in complete resolution of ED.

In case 3, we have reported ATRA-induced necrotic scrotal ulceration. Literature review revealed that over the last two decades, a total of twenty cases of ATRA-induced scrotal ulceration have been reported. Histopathological evaluation of these lesions revealed atypical granulocytic infiltration, pointing towards the possible etiological role of differentiated APL cells in the pathogenesis. Most of these cases, including ours, developed genital-lesions almost after two weeks of ATRA exposure and remained unresponsive to local and systemic antibiotics. ATRA had to be halted in most of the cases to prevent progression to fournier’s gangrene [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ].

Scattered over the span of three years and considered in isolation, it was not initially apparent to us that all three cases had one striking similarity: concomitant use of ATRA and triazole antifungals. ATRA is primary metabolized by cytochrome P450 enzyme system. Triazole antifungals are notorious for their strong inhibitory effect on CYP450 enzyme system, resulting in supra-therapeutic drug levels and toxicity [ 20 , 21 , 22 ].

Potentiation of serum ATRA levels by inhibition of CYP450 system was first explored by Rigas et al. [ 23 ]. This study reported 1.8 times higher serum concentration of ATRA with concomitant use of ketoconazole. Since then a number of cases have reported the augmentation of ATRA-induced toxicities due to this pharmacokinetic interaction. Concomitant use of ATRA and triazole antifungals that is voriconazole and posaconazole has been implicated to cause severe hypercalcemia [ 24 , 25 , 26 , 27 ]. Similarly, combination with fluconazole has been reported to cause severe neurotoxicity and nephrotoxicity [ 28 , 29 ].

Considering the temporal association of dermatological complications with triazole antifungals in our patients, we speculate that the concomitant use of triazole antifungals inhibited the metabolism of ATRA, resulting in higher serum concentrations and markedly accentuated cutaneous toxicities. A study further strengthening our hypothesis was conducted by Kurzrock et al. to evaluate the maximum tolerable dose of ATRA in myelodysplastic syndrome. The study reported severe dose-limiting cutaneous toxicities, such as generalized desquamation and genital ulceration, at doses > 150 mg/m 2 /day, compared to mild xerosis and erythema in the dose range of 45–100 mg/m 2 /day. Akin to our cases, the study reported complete resolution of cutaneous toxicities within 1–2 weeks of ATRA discontinuation [ 30 ].

Another important point is the recurrence of ED in both case 1 and 2 during their consolidation chemotherapy cycles, whereas recurrent scrotal ulceration was not documented in case 3. The most likely explanation is the continuation of voriconazole as secondary prophylaxis in patients with invasive fungal infections (IFI) (case 1 and 2), whereas itraconazole was discontinued after remission induction in case 3. This once again underscores the pharmacokinetic potentiation of ATRA-induced cutaneous toxicities by triazole antifungals. An important limitation of our study is that, due to the unavailability of serum voriconazole testing, we couldn’t document serum voriconazole levels, something that could provide valuable insights into the effect of serum azole levels on the severity of cutaneous manifestations.

By highlighting this crucial pharmacokinetic interaction and its potentially severe implications, we urge our fellow oncologists to remain vigilant regarding the inhibitory effects of triazole antifungals on the metabolism of ATRA. We propose the use of a non-myelosuppressive combination of ATRA and arsenic trioxide for APL, thereby eliminating the need for prophylactic antifungals. In the case of invasive fungal infections (IFI), we recommend considering alternative classes of antifungals. However, if triazole antifungals are deemed unavoidable, we suggest close monitoring for potential side effects and implementing prophylactic measures as clinically necessary.

Availability of data and materials

Data sharing is not applicable to this manuscript as no datasets were generated or analyzed during the current study.

Abbreviations

Acute promyelocytic leukemia

All-trans retinoic acid

Cytochrome P450

Differentiation syndrome

• Exfoliative dermatitis

High-resolution computerized tomography

Invasive fungal infections

Promyelocytic leukemia-retinoic acid receptor alpha

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Aisha Jamal, Rafia Hassam, Qurratulain Rizvi, Ali Saleem & Nida Anwar

Research and Development, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan

Anum Khalid

Department of Clinical Haematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Plot # Special D-3, Block-6, (Across Railway Line), P.E.C.H.S, Karachi, Pakistan

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Aisha Jamal: Conceptualization, writing-original draft, writing-review & editing. Rafia Hassam: Conceptualization, writing-original draft. Qurratulain Rizvi: Writing-review & editing. Ali Saleem: Data curation, writing—review & editing. Anum Khalid: Writing—review &editing. Nida Anwar: Writing—review & editing.

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Jamal, A., Hassam, R., Rizvi, Q. et al. A rare incidence of severe dermatological toxicities triggered by concomitant administration of all-trans retinoic acid and triazole antifungal in patients with acute promyelocytic leukemia: a case series and review of the literature. J Med Case Reports 18 , 261 (2024). https://doi.org/10.1186/s13256-024-04577-1

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Received : 19 December 2023

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DOI : https://doi.org/10.1186/s13256-024-04577-1

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