Diltiazem-induced palmar desquamation and oral erosions.

To cite: Toescu SM, Kennon S, Stevens H. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201536 DESCRIPTION A 64-year-old man presented with a 12-month history of angina. Following coronary angiography he underwent percutaneous coronary intervention with deployment of drug-eluting stents to the left anterior descending and main diagonal branch. He was discharged on diltiazem 200 mg daily as an antianginal and antihypertensive drug, aspirin, clopidogrel and atorvastatin; as well as his regular medications omeprazole and fluoxetine. When reviewed 2 weeks later he was free of angina but had developed skin shedding and peeling affecting the palmar surfaces of both the hands (figure 1), and oral erosions (figure 2) of the tongue and mouth; the feet were spared. Diltiazem-induced palmar-plantar desquamation (PPD) was diagnosed; diltiazem was discontinued, a urea-containing emollient was prescribed and the skin condition resolved completely over the next fortnight. PPD is clinically manifested as an exfoliative peeling of the stratum corneum of the glabrous epidermis. This may be part of a spectrum of skin disease seen with diltiazem from PPD through to generalised exfoliative dermatitis. PPD has been reported previously with diltiazem. To the best of our knowledge, there are no reports of concomitant involvement of the buccal mucosa, though this may be explained by similar keratins (types 6 and 16) being expressed in both the palmar-plantar epidermis and in the mouth. PPD can be caused by other calcium channel blockers, although with less propensity than diltiazem. It also occurs as a side effect of amiodarone, enalapril and phenindione, and with chemotherapeutic drugs. Clinicians should be aware of the adverse cutaneous effects of diltiazem suggested by this case.