Cyclosporine in the management of poststreptococcal pustulosis.

Report of a Case | Awoman in her 50s and her daughter, in her 30s, presented simultaneously with painful pustules on the palms (Figure, A) and a few on the soles. The eruption began 5 days after culture-proven group A streptococcal pharyngitis in thedaughter and tonsillitis in themother. Bothwere systemicallywell with no fever, arthropathy, ormucosal lesions. Both patients had already received a week of oral cephalexin therapybecausepustules continued todevelop. Therewasno medical or family history of psoriasis. Themother had type 2 diabetes mellitus. Laboratory investigations revealed leukocytosis in the mother (leukocytes, 13.5 × 109/L; neutrophils, 9.1 × 109/L; eosinophils 0.3 × 109/L) and daughter (leukocytes, 12.2 × 109/L; neutrophils, 7.2 × 109/L; eosinophils 0.3 × 109/L) (normal leukocyteupper limit, 10.5 × 109/L). (To convert leukocytes, neutrophils, and eosinophils to cells per microliter, divide by 0.001.) Cultures of the pustules were sterile. There were no signs of renal involvement: urinalysis findings and serumcreatinine levels were normal. Human leukocyte antigen typing and biopsy were not performed. We elected to treat both patients with cyclosporine as an alternative toprednisone.Thisdecisionwasbasedon the rapid action of cyclosporine, its direct suppressive effect on cytokines that influence neutrophils,2 and no hyperglycemic adverse effectswhen comparedwith corticosteroids. The patientswereprescribedoral cyclosporine, 50mg, twicedaily for 3 days (approximately 1mg/kg/d), then 25mgbymouth twice daily for 3 days. Both patients reported marked reduction in pain within 48 hours and dramatic improvement of the lesions within 1 week (Figure, B). Because the lesions responded rapidly, we discontinued cyclosporine treatment after the initial course. There were no reported adverse effects of cyclosporine and no recurrences after 1 year of follow-up.