Abstract: A 67 year-old man developed a generalized
dermatitis 2 weeks after starting pravastatin.
HPI: This previously healthy 67-year-old man developed a scaly eruption on his
forehead approximately 10 to 14 days after starting pravastatin. While his lipid profile was not very
worrisome his PCP recommended the statin based on new guidelines. The eruption spread and generalized over the
next one to two weeks when he stopped the statin.
O/E: He presented with a generalized process. This had features of an erythroderma with
islands of sparing. There is a marked palmoplantar hyperkeratosis with desquamation. There was an early
ectropion of the lower eyelids. There is no lymphadenopathy.
Clinical Photos:
Lab: CBC and CMP are within normal range, need lipid profile
Microscopic Images:
Photomicrographs courtesy of Hyejin Leah Chung, M.D. Dermatopathology at Boston University
Photomicrographs courtesy of Hyejin Leah Chung, M.D. Dermatopathology at Boston University
H&E x 200
Alternating orthokeratosis and parakeratosis in both vertical and horizontal directions, a few scattered keratinocytes with perinuclear vacuolization
H&E x 100
Follicular plugging with foci of parafollicular parakeratosis, subtle regular acanthosis with a rounded lower border
Diagnosis: Most likely statin related PRP
Questions: Is acitretin the drug of choice in this
clinical situation? Is it preferable to
isotretinoin?
References:
2) Dicken CH. Treatment of classic pityriarsis rubra pilaris. J Am Acad Dermatol. 1994; 31(6):997-9
3) Adult pityriasis rubra pilaris: a 10-year case series.
Clayton BD1, Jorizzo JL et. al J Am Acad Dermatol. 1997
Jun;36:959-64.
Abstract
BACKGROUND:
Pityriasis rubra pilaris (PRP) often has a devastating
impact on the lives of patients. Descriptions of its histopathologic features
are not uniform. Finding a successful therapy can be challenging.
OBJECTIVE:
Our purpose was to examine the histopathologic features and
response of patients to our standard therapy of an oral retinoid and
concomitant or later addition of low-dose weekly methotrexate.
METHODS:
A retrospective chart review was done on 24 patients with
PRP seen from March 1986 to March 1996. Biopsy specimens from 19 patients were
reexamined. Telephone follow-up was conducted to determine maintenance of
remission.
RESULTS:
All patients had the adult acquired form of PRP. Biopsy
specimens from nine patients were characterized by prototypical findings of
PRP, while the others included both typical and other features. Twenty-two
patients were treated with either isotretinoin, 40 mg twice daily, or
etretinate, 25 to 75 mg/day. Six patients with more disabling involvement had
low-dose weekly methotrexate ranging from 5 to 30 mg started concurrently. Five
patients had weekly methotrexate added at a later time. Seventeen patients
showed 25% to 75% response after 16 weeks of therapy. All patients whose skin
cleared maintained their remission.
CONCLUSION:
Initial oral retinoid plus concurrent or later low-dose
weekly methotrexate resulted in 25% to 75% improvement of PRP in 17 of 24
patients after 16 weeks of therapy. Some of the atypical features seen in
biopsy specimens emphasize the importance of clinical and histopathologic
correlation in establishing the diagnosis.
Dr, Bhushan Kumar from Chandigarh, India writes: "A combination of isotretinoin (daily) and methotrexate (weekly) is much better and safer rather than giving either of the drugs alone. Isotretinoin is cheaper and better tolerated than acitretin. The treatment has to be continued close to six months with regular haematological and lipidogram monitoring.
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