Dermographism: an adverse effect of atorvastatin.

Dermographism, or skin writing, is the most common type of physical urticaria, manifesting as pruritic linear wheals and erythema secondary to minor trauma, such as rubbing or stroking the skin. This reaction in the superficial dermis occurs within seconds to minutes after mechanical irritation and typically resolves within 1 to 2 hours. Usually there are no associated systemic signs and symptoms. Precipitating factors can include viral infections, antibiotics, and emotional distress. In most cases, however, the cause is unknown. Atorvastatin (Lipitor) is a synthetic 3-hydroxy3-methyglutaryl coenzyme A (HMG-CoA) reductase inhibitor commonly used in treatment of hypercholesterolemia. Atorvastatin and other HMGCoA reductase inhibitors have been well tolerated with similar adverse effect profiles. Less than 2% of 2,502 patients in a postmarketing atorvastatin study withdrew from the study because of adverse effects. The most common adverse effects include gastrointestinal disturbances, such as dyspepsia, abdominal pain, constipation, and flatulence. More serious adverse effects are liver insufficiency and myopathy. Cutaneous adverse reactions secondary to HMG-CoA reductase inhibitors are infrequent, which might be explained by extensive first-pass metabolism in the liver resulting in low serum concentrations. HMG-CoA reductase inhibitors have been implicated with eczematous rashes, lichenoid eruptions, cheilitis, and ichthyosis-like reactions. These reactions have been explained by decreased epidermal cholesterol synthesis leading to impairment of the cutaneous barrier function. In addition, HMG-CoA reductase inhibitors have been associated with toxic epidermal necrolysis, urticaria, angioedema, photosensitivity, and radiation recall. To our knowledge, this case is the first reported of dermographism thought to be related to any HMG-CoA reductase inhibitor. Inhibition of epidermal cholesterol synthesis does not appear to explain dermographism.