Microsoft Word - DRM053aBF

M.J. Korstanje, Department of Dermatology, Academic Hospital Maastricht, PO Box 1918, NL–6201 BX Maastricht (The Netherlands) The effectiveness of ciclosporin (CsA) in severe plaque psoriasis is established [1. 2]. However. CsA may not be randomly used in clinical practice because of its side effects, which include hepatotoxicity. acute and chronic nephrotoxicity, hirsutism. hypertension and toxic effects on the central nervous system [3]. We here present a case of permanent renal impairment after treatment with CsA in a patient with pustular psoriasis and acrodermatitis continua (Hallopeau). The effectiveness of CsA treatment in this patient has been published previously [4]. Case Report. A 61-year-old healthy man, without a medical history, had therapy-resistant generalized pustular psoriasis and acrodermatitis continua (Hallopeau) since 1985. In 1988 oral therapy with CsA 8.0 mg/ kg/day (CsA trough level 600 ng/ml) was started in combination with prednisone 10 mg/day. Within 3 weeks the skin was completely clear except for persistent severe nail lesions. Tapering off CsA or prednisone resulted in an exacerbation of acrodermatitis continua and pustular psoriasis. Therefore CsA and prednisone therapy was continued with unchanged dose. No concomitant medication was used. Within a month serum creatinine started to rise to 157 μmol/l. In cooperation with the department of internal medicine, therapy was continued. After 3 months hypertension developed which could be controlled by atenolol 100 mg/day and furosemide 40 mg/day. Other side effects did not occur except for a slight increase in gammaGT. ALAT and LDH. Within 12 months of CsA treatment, serum creatinine rose from 84 to 344 μmol/l. After CsA was lowered to 5.0 mg/kg/day (CsA trough level 290 ng/ml). gammaGT. ALAT and LDH normalized while serum creatinine decreased slowly in the following months. Hypertension however was persistent. Unfortunately the patient’s pustular psoriasis and acrodermatitis continua could not be controlled with this dose. Even a combination therapy of CsA with etretinate and local therapy was not effective. Therefore CsA was discontinued and the patient was subsequently treated with methotrexate. He received CsA treatment during 18 months. When CsA treatment was discontinued, serum creatinine was 196 μmol/l. In the following 6 months blood pressure normalized and serum creatinine decreased to 138 μmol/l. Six months later serum creatinine was unchanged with a glomerular filtration rate of 53 ml/min and an extra renal plasma flow of 200 ml/min. Discussion. Monotherapy CsA for generalized pustular psoriasis and acrodermatitis continua requires a high CsA dose [4. 5]. This can cause side effects as renal impairment within a short time. Long-term CsA treatment for pustular psoriasis or acrodermatitis continua is therefore not possible.