A case of generalized pustular psoriasis caused by hydroxychloroquine in a patient with systemic lupus erythematosus

Abstract

Hydroxychloroquine (HCQ) has been used to treat systemic lupus erythematosus (SLE) in Japan since 2015. We herein report a case of SLE that developed generalized pustular psoriasis (GPP) following the administration of HCQ. Twenty-one days after the HCQ treatment, a pustular rash with itching appeared on the auricle, scalp, and forearm, and spread rapidly to the face and body trunk with a high fever and arthralgia. Skin biopsy showed pustule formation under the cornified layer, neutrophil infiltration, the destruction of keratinocytes, and spongiform pustules of Kogoj. The patient was diagnosed with GPP. HCQ was immediately discontinued, the dose of prednisolone (PSL) was increased, and granulocyte and monocyte adsorption apheresis was performed. Her symptoms subsequently disappeared. Since arthralgia relapsed after the tapering of PSL, cyclosporine was added. Although single nucleotide polymorphisms (c.28C>T and c.115+6T>C) in the interleukin (IL)-36RN gene, which encodes the IL-36 receptor antagonist, have frequently been reported in GPP, these mutations were not observed in the present case. The potential development of GPP needs to be considered when administering HCQ to patients with SLE.

Keywords

Hydroxychloroquine generalized pustular psoriasis systemic lupus erythematosus

Get full access to this article

View all access options for this article.

References

Ochsendorf FR. Use of antimalarials in dermatology. J Dtsch Dermatol Ges 2010; 8: 829–844.

Umezawa

Ozawa

Kawashima

et al.

Therapeutic guidelines for the treatment of generalized pustular psoriasis (GPP) based on a proposed classification of disease severity. Arch Dermatol Res 2003; 295(Suppl 1): S43–54.

Sugiura

Takemoto

Yamaguchi

et al.

The majority of generalized pustular psoriasis without psoriasis vulgaris is caused by deficiency of interleukin-36 receptor antagonist. J Invest Dermatol 2013; 133: 2514–2521.

Marrakchi

Guigue

Renshaw

et al.

Interleukin-36 receptor antagonist deficiency and generalized pustular psoriasis. N Engl J Med 2011; 365: 620–628.

Friedman

. Pustular psoriasis associated with hydroxychloroquine. J Am Acad Dermatol 1987; 16: 1256–1257.

Vine

Hymes

Warner

Cohen

. Pustular psoriasis induced by hydroxychloroquine: a case report and review of the literature. J Dermatol 1996; 23: 357–361.

Gravani

Gaitanis

Zioga

Bassukas

. Synthetic antimalarial drugs and the triggering of psoriasis—do we need disease-specific guidelines for the management of patients with psoriasis at risk of malaria? Int J Dermatol 2014; 53: 327–330.

Fujita

Terui

Hayama

et al.

Japanese guidelines for the management and treatment of generalized pustular psoriasis: the new pathogenesis and treatment of GPP. J Dermatol 2018; 45: 1235–1270.