Recurrence of psoriasis in an arteriovenous fistula

A 63-year-old Kenyan Asian man began haemodialysis involvement, the risk of secondary infection leading to either line sepsis or peritonitis, and the difficulties in in April 1997. He initially presented in 1988 dialysis dependent with an ANCA-associated systemic vasculperforming surgical procedures through involved skin. Koebner’s phenomenon (the recurrence of skin lesions itis, and was treated with plasmapheresis, prednisolone and azathioprine. His renal function initially recovered at sites of trauma or scars) is a common finding in severe plaque psoriasis and has been reported to occur (creatinine 200 mmol/l ), but over the next decade he had slowly progressive renal failure. He had suffered at Tenkhoff exit sites, and along Tenkhoff insertion scars [4], but not at the needling sites of fistulae. from extensive plaque psoriasis for 25 years, and had three hospital admissions during this time for treatment Interestingly acupuncture has been known to initiate plaque formation in psoriasis [6 ]. The aetiopathology of his psoriasis. Previous treatments included dithranol, crude coal tar, PUVA and acitretin, in addition to of the Koebner reaction is poorly understood, but recruitment of CD4+ T lymphocytes into sites of injury standard topical regimens. Haemodialysis was instituted in April 1997 via an occurs early in the development of the reaction, and is associated with the upregulation of ICAM-1 on epiinternal jugular permacath. At this time he had extensive plaque psoriasis covering his torso, arms, legs and dermal keratinocytes [7]. The development of psoriatic plaques themselves correlates with the subsequent invascalp. Within 1 week of starting dialysis he developed new psoriatic lesions over his permacath exit site, sion of CD8+ lymphocytes [8]. Our patient developed Koebner’s reaction at fistula which did not compromise the use of the catheter. Two months later he was admitted to hospital for inneedling sites despite systemic treatment for his psoriasis with cyclosporin, and had not shown an improvepatient treatment of worsening erythrodermic psoriasis, with soft paraffin, aqueous cream, betnovate, ment in his psoriasis after starting dialysis. diprosalic ointment, trimovate, polytar, emulsifying ointment and occlusion therapy, and was begun on oral cyclosporin at 3 mg/kg/day. His psoriasis References improved and subsequently he began dialysing through a forearm arteriovenous fistula. After three dialysis 1. Bargman JM. Nonuremic indications for peritoneal dialysis. Perit Dial Int 1993; 13 [Suppl 2]: S159–164 sessions he developed large psoriatic plaques over the 2. Nissenson AR, Rapaport M, Gordon A, Narins RG. needling sites along his fistula (Koebner’s phenomHemodialysis in the treatment of psoriasis. A controlled trial. enon, Figure 1), making further use of the fistula Ann Intern Med 1979; 91: 218–220 impossible. The Koebner reaction subsided after sev3. Sobh MA, Abdel-Rasik MM, Moustafa FE et al. Dialysis therapy of severe psoriasis: a random study of forty cases. Nephrol Dial eral weeks. He continues to dialyse through a permaTransplant 1987; 2: 351–358 cath and his psoriasis remains difficult to control. 4. Twardowski ZJ, Lempert KD, Lankhorst BJ et al. Continuous Both haemodialysis and peritoneal dialysis have been ambulatory peritoneal dialysis for psoriasis. A report of four used to treat extensive psoriasis even in patients withcases. Arch Intern Med 1986; 146: 1177–1179 5. Whittier FC, Evans DH, Anderson PC, Nolph KD. Peritoneal out renal failure [1]. A number of small controlled dialysis for psoriasis: a controlled study. Ann Intern Med 1983; studies including sham haemodialysis or sham periton99: 165–168 eal dialysis have been conducted, with mixed results 6. Kirschbaum JO. Koebner phenomenon following acupuncture. [2–5]. In patients with renal failure, psoriasis can Arch Dermatol 1972; 106: 767 hinder the delivery of effective renal replacement 7. Paukkonen K, Naukkarinen A, Horsmanheimo M. The development of manifest psoriatic lesions is linked with the appearance therapy of any modality because of the degree of skin of ICAM-1 positivity on keratinocytes. Arch Dermatol Res 1995; 287: 165–170 8. Paukkonen K, Naukkarinen A, Horsmanheimo M. The development of manifest psoriatic lesions is linked with the invasion of Correspondence and offprint requests to: Renal Section, Division of Medicine, Imperial College School of Medicine, Hammersmith CD8+ T cells and CD11c+ macrophages into the epidermis. Arch Dermatol Res 1992; 284: 375–379 Hospital, Ducane Road, London W12 0NN, UK.