Clopidogrel: A possible exacerbating factor for psoriasis
This 64-year-old human immunodeficiency virus-negative, non-smoker and non-alcoholic male patient presented with pustular psoriasis involving both palms and soles for the past >2years with waxing and waning clinical course. There was no personal or family history of psoriasis previously. Historically, he had developed acrodermatitis continua of Hallapeu-like skin lesions 7-8 months after taking treatment for a clinically suspected CAD despite having a normal electorcardiogram, echocardiography and treadmill test. Patient was taking diltiazem (75 mg/d), atenolol (50 mg/d), aspirin (75 mg/d) and atorvastatin (10 mg/d). Since both the drugs are known to precipitate/aggravate psoriasis atenolol and aspirin were stopped and clopidogrel 75 mg/d was prescribed by his physician. However, his skin lesions progressed relentlessly eventuating into palmoplantar psoriasis with pustulosis []. A skin biopsy from a pustular lesion showed hyperkeratosis, parakeratosis, acanthosis, papillomatosis and papillary neutrophilic collection suggestive of psoriasis having pustular differentiation []. He did not improve with topical emollients, tar and corticosteroid ointments and developed intolerable retching/vomiting after systemic methotrexate (15 mg/week). Although he continued with topical treatment, his skin lesions did not remit. However, his skin lesions disappeared completely within a month when he stopped all medications which were for CAD without his physician's advice. He did not develop any skin lesions after restarting diltiazem and atorvastatin on the insistence of his physician but these returned within a week after taking clopidogrel (75 mg/d) re-challenge (performed with his consent). Since then he has stopped all his drugs on his own and is free of psoriasis and has not developed any symptoms/signs of CAD.