Microsoft Word - DRM088BF

Retinoids Cyclosporin A Erythroderma Psoriasis A.L.A. Kuijpers, Department of Dermatology, University Hospital Nijmegen, PO Box 9101, NL-6500 HB Nijmegen (The Netherlands) Psoriatic erythroderma is a serious condition which requires a fast response to therapy, preferably during an in-patient treatment. Therapeutic options include various topical treatments and photo(chemo)-therapy, but in most cases systemic treatment is necessary [1]. Combination of cyclosporin A and methotrexate (MTX) resulted in serious adverse events after a short treatment period, and therefore is not recommended [2]. Combination of etretinate and MTX may lead to increased hepatotoxic risks, by increasing the MTX plasma levels [3,4]. Because of the different mechanisms of action and a different side effect profile combined treatment of cyclosporin A and retinoids might be successful. Three patients with psoriatic erythroderma, who did not respond to monotherapy with acitretin in adequate dosages, were treated with combined therapy consisting of acitretin and cyclosporin A. They did not use co-medication known to interact with cyclosporin A metabolism or with nephrotoxic potentials. Serum creatinine level, liver enzymes, serum electrolyte levels, haematological parameters and blood pressure were measured before initiating combination treatment and once weekly during therapy. Clinical scores were evaluated using the Psoriasis Severity Score modified according to Perkins et al. [5]. The individual dosages, clinical efficacy and side effects of each patient are summarised in table 1. Case 1 A 58-year-old man was admitted because of a biopsy-proven psoriatic erythroderma. He had been treated with acitretin in a dosage of 0.5 mg/kg/day during 12 weeks. Because of lack of clinical improvement, combination therapy was started with cyclosporin A in a dosage of 3 mg/kg/day. After 1 week of combined treatment, acitretin was decreased to 0.3 mg/kg/day because of a retinoid-induced dermatitis. After 6 weeks the serum creatinine level was elevated > 40%, and the serum cholesterol level and the blood pressure were raised. No clinical improvement was achieved during 6 weeks treatment. Both therapies were stopped and MTX was started at a dosage of 7.5 mg/week. After 2 weeks the blood pressure and the cholesterol