GENERALIZED PUSTULAR PSORIASIS PRECIPITATED BY TOPICAL CALCIPOTRIOL CREAM

An 18-year-old woman had a 3-year history of previously stable plaque-type psoriasis that covered most parts of her body, arms, and legs. In June 1993, she started treatment with calcipotriol cream, which was prescribed by her dermatologist. Two weeks after starting this treatment, she had an exacerbation of her psoriasis with a generalized pustular eruption and she was admitted to the dermatology unit of “A. Sygros” Hospital. On admission, the clinical examination revealed a bright red erythema of most of her skin and numerous pinhead-sized pustules that covered all the psoriasis lesions (Fig. 1). The eruption covered the patient's body, legs, and arms, whereas flexures and genitalia remained free. She also complained of malaise. The patient's laboratory studies showed the following values: hemoglobin 12.8 g/dL; hematocrit 39%; WBC 14,000/mm³; platelets 28,000/mm³; erythrocyte sedimentation rate 48/h. The blood chemistry surveys were all in the normal range and so were all enzyme studies. Urinalysis was normal. Chest x-ray showed no abnormality. Previous treatment During the 3-year history, the patient had been using different treatments to control her disease. The last treatment was fluocinamide 0.05% cream, which she had stopped 8 weeks before starting treatment with calcipotriol. On clinical examination no signs of cutaneous atrophy, suggesting the overuse of topical steroid, was found. Histopathologic Findings A 4-mm punch biopsy was taken from a lesion and it revealed the epidermis to be slightly acanthotic and the formation of intraepidermal pustules underneath the stratum corneum with spongiform pustules at the shoulders of the lesion. In the dermis there was a perivascular infiltrate of lymphocytes and a few neutrophils with dilatation of blood vessels (Fig. 2). Course Calcipotriol cream was immediately withdrawn and treatment with methotrexate (MTX) was started (25 mg i.m. weekly). The dose was gradually decreased and discontinued 8 weeks later with no relapse of pustules or the plaque-type psoriasis until now.