Acute pustular psoriases complicated by leukocytoclastic vasculitis

Journal of Drugs in Dermatology, April, 2003 by Michael Jude Welsch

The differential diagnosis of a patient with a pustular eruption includes pustular psoriasis, acute generalized exanthematous pustulosis (AGEP), and infection. AGEP is usually triggered by a drug in a patient without a prior history of psoriasis. Its course is characterized by rapid spontaneous healing (25). Infectious causes are ruled out by negative gram stain and cultures. In our case, the arcuate nature of the plaques, history of arthritis consistent with psoriatic arthritis, exacerbation by oral corticosteroids, associated toxicity, and slow response to treatment argues in favor of pustular psoriasis.

Therapy is aimed initially at identification and removal of any offending agents. Retinoids such as acitretin at doses of 0.5-1.0 mg/kg/day leads to rapid clearing of pustulation (18,26). Methotrexate (15,18), hydroxyurea (15,18,27), dapsone (18,28), photochemotherapy (10,18), and cyclosporin (29) have also been used with varying degrees of efficacy.

Leukocytoclastic vasculitis (LCV) is a histologic diagnosis characterized by segmental inflammation and fibrin deposition within blood vessels with fragmentation of polymorphonuclear leukocytes and formation of nuclear dust (leukocytoclasis). Infections, chemicals, foods, and drugs can precipitate LCV. LCV may also occur in association with chronic diseases and malignant neoplasms. No cause is identified in 60% of cases (30). The fluoroquinolones ciprofloxacin and ofloxacin have been reported previously as provocative agents of LCV (31,32), but this is the first reported case suggesting levofloxacin-induced LCV.

Table I. Reported Inciting Agents for Pustular Psoriasis

Anti-inflammatories   NSAIDS: oxyphenbutazonel, phenylbutazone (1),
                      salicylates (2)
                      Oral corticosteroids withdrawal (3)
Antimalarials         Hydroxychloroquine (4)
Antimicrobials        Penicillin (5), sulfonamides (6), terbinafine (7)
Beta blockers         Atenolo (18) propranolo (19)
Psychotropics         Lithium carbonate (30), trazodone (11)
Topicals              Calcipotriol cream (12), coal tap
Others                Cyclosporin withdrawal (14), morphine (15),
                      potassium iodide (16)

References

(1) Reshad H, Hargreaves GK, Vickers CF. Generalized pustular psoriasis precipitated by phenylbutazone and oxyphenbutazone. Br J Dermatol 1983; 109:I l 1-113.

(2) Shelley WB. Birch pollen and aspirin psoriasis. A study of salicylate hypersensitivity. JAMA 1964; 189:985-988.

(3) Baker H. Corticosteroids and pustular psoriasis. Br J Dermatol 1976; 94:83-88.

(4) Vine JE, Hymes SR, Warner NB, et al. Pustular psoriasis induced by hydroxychloroquine. A case report and review of the literature. J Dermatol 1996; 23:357-361.

(5) Katz M, Seidenbaum M, Weinrauch L. Penicillin-induced generalized pustular psoriasis. J Am Acad Dermatol 1987; 17:918-920.

(6) Ryan TJ and Baker H. The prognosis of generalized pustular psoriasis. Br J Dermatol 1971; 85:407-411.

(7) Gupta AK, Sibbald RG, Knowles SR, et al. Terbinafine therapy may be associated with the development of psoriasis de novo or its exacerbation: four case reports and a review of drug-induced psoriasis. J Am Acad Dermatol 1997; 36:858-862.