Cutaneous reactions induced by calcium channel blocker: high frequency of psoriasiform eruptions

Psoriasiform drug eruption: A case series with a review of the literature

The present case series examined five instances of psoriasiform drug eruption diagnosed between 2014 and 2022 at the study site and 23 cases of drug eruption manifesting psoriasiform lesions which had been reported between 1986 and 2022. The causative drug, distribution of the skin eruptions, clinical latency to eruption, treatment course, and histopathological findings were investigated. The most common causative agents were calcium channel blockers (CCB) (64.5%). Of the 28 cases of psoriasiform drug eruption for which details of the eruption sites were reported, 46.4% occurred on the face, which was slightly higher than the usual distribution of psoriasis. CCB were responsible for 80.0% of the cases of facial skin rash. The mean time from the administration of the suspected drug to eruption onset was 25.0 months (range: 0.5-120 months; median: 13.0 months). In all the cases, the skin rash improved after the causative drug was discontinued. CCB were the most common causative agent, and the eruptions more commonly occurred on the face than in normal psoriasis, suggesting that it is especially important to confirm whether there is a history of CCB administration in psoriasis patients with extensive, facial skin eruptions.

Antihypertensive drug use and psoriasis: A systematic review, meta- and network meta-analysis

AIMS

Diverse genetic and/or external factors may induce psoriasis. Drug exposure is 1 such prominent external factor; antihypertensive drugs are reportedly associated with psoriasis, but study results have been inconsistent. In this context, we investigated the associations between antihypertensive drugs and incidence if psoriasis via a systematic literature review and meta-analysis.

METHODS

Literature search in databases such as PubMed, Embase and Web of Science was conducted on 8 January 2021, and obtained data were pooled for meta- and network meta-analysis. Fixed- or random effect models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for evaluating the strength of the associations between antihypertensive drugs and psoriasis incidence. In addition to meta-analysis, Bayesian network meta-analysis was performed. ResultsThirteen eligible studies were included for meta-analysis with 6 378 116 individuals and 8 studies for network meta-analysis with 5 615 918 individuals. All antihypertensive drugs were significantly associated with psoriasis incidence. In a meta-analysis, the pooled ORs were 1.67 (95% CI: 1.31-2.13) for angiotensin-converting enzyme (ACE) inhibitors, 1.40 (95% CI: 1.20-1.63) for β-blockers, 1.53 (95% CI: 1.23-1.89) for calcium-channel blockers (CCBs), and 1.70 (95% CI: 1.40-2.06) for thiazide diuretics. For the comparative risks of psoriasis among antihypertensive drugs in the network meta-analysis, ORs were 2.09 (95% CI: 1.39-3.18) for ACE inhibitors, 1.35 (95% CI: 0.99-1.91) for BBs, 1.53 (95% CI: 1.07-2.24) for CCBs and 1.80 (95% CI: 1.23-2.66) for thiazide diuretics.

CONCLUSION

This study confirmed the associations between antihypertensive drugs and psoriasis; ACE inhibitors, BBs, CCBs and thiazide diuretics increased the risk of psoriasis. Therefore, antihypertensive drug users should be carefully monitored for psoriasis.

Prediction of Hypertension Based on Facial Complexion

This study aims to investigate the association between hypertension and facial complexion and determine whether facial complexion is a predictor for hypertension. Using the Commission internationale de l'éclairage L*a*b* (CIELAB) color space, the facial complexion variables of 1099 subjects were extracted in three regions (forehead, cheek, and nose) and the total face. Logistic regression was performed to analyze the association between hypertension and individual color variables. Four variable selection methods were also used to assess the association between hypertension and combined complexion variables and to compare the predictive powers of the models. The a* (green-red) complexion variables were identified as strong predictors in all facial regions in the crude analysis for both genders. However, this association in men disappeared, and L* (lightness) variables in women became the strongest predictors after adjusting for age and body mass index. Among the four prediction models based on combined complexion variables, the Bayesian approach obtained the best predictive in men. In women, models using three different methods but not the stepwise Akaike information criterion (AIC) obtained similar AUC values between 0.82 and 0.83. The use of combined facial complexion variables slightly improved the predictive power of hypertension in all four of the models compared with the use of individual variables.

Use of calcium channel blockers in dermatology: a narrative review

Introduction: Calcium channel blockers (CCB) are commonly used for cardiovascular diseases. The evidence supporting the use of CCB in dermatology is mostly anecdotal and limited to case reports or small case series.Areas covered: This review article is divided into two parts. The first part discusses the therapeutic use of CCB in dermatology. The second part focuses on mucocutaneous adverse reactions due to the administration of CCB.Expert opinion: The use of CCB in dermatology is mainly based on its properties as a vasodilator and the inhibition of muscle contractions, such as pernio, anal fissures, facial wrinkles, and painful leiomyoma. However, there remain other modes of action to explain its clinical use in calcinosis, keloid, pressure ulcer, and fibromatosis. Compared to oral CCB, the lack of systemic side effects would make topical use of CCB an attractive alternative in the treatment of skin diseases, but the evidence for topical CCB is still limited, and there is a lack of standardized topical formulation. The main mucocutaneous adverse effects of CCB include gingival hyperplasia, phototoxicity, eczema, psoriasis and risk of skin cancers. Plausible factors for these adverse events include CCB's photoinstability, aldosterone synthesis inhibition, disturbed calcium homeostasis and immunosuppressive properties.

Verapamil, a Calcium-Channel Blocker, Improves the Wound Healing Process in Rats with Excisional Full-Thickness Skin Wounds Based on Stereological Parameters

OBJECTIVE

Calcium can play noticeable roles in the wound-healing process, such as its effects on organization of F-actinin collagen bundles by fibroblasts at the injury site. In addition, calcium-channel blockers such as verapamil have antioxidant activity by increasing nitric oxide production that promotes angiogenesis, proliferation of fibroblasts, and endothelial cells in the skin-regeneration process. Therefore, in this study, the authors' objective was to investigate the effects of verapamil on the process of wound healing in rat models according to stereological parameters.

MATERIALS AND METHODS

In this experimental study, 36 male Wistar rats were randomly divided into 3 groups (n = 12): the control group that received no treatment, gel-base-treated group, and the 5% verapamil gel-treated group. Treatments were done every 24 hours for 15 days. Wound closure rate, volume densities of the collagen bundles and the vessels, vessel's length density and mean diameter, and fibroblast populations were estimated using stereological methods and were analyzed by the Kruskal-Wallis and Mann-Whitney U tests; P < .05 was considered statistically significant.

RESULTS

The verapamil-treated group showed a faster wound closure rate in comparison with control and gel-base groups (P = .007 and P = .011). The numerical density of fibroblasts, volume density of collagen bundles, mean diameter, and volume densities of the vessels in the verapamil group were significantly higher than those in the control and the base groups (P < .005).

CONCLUSIONS

The authors showed that verapamil has the ability to improve wound healing by enhancing fibroblast proliferation, collagen bundle synthesis, and revascularization in skin injuries.

Bullous Eruption Associated With Dihydropyridines With Cross Reactivity

The spectrum of cutaneous eruptions associated with dihydropyridines is extensive, varying from exanthemas to severe adverse events. We report a case of bullous eruption, one month after starting nicardipine and lercanidipine. The same symptoms recurred few days after taking nitrendipine.

Triggering drug use in patients with psoriasis: an investigative report from Turkey

INTRODUCTION

The patients clinically diagnosed with psoriasis were investigated for drug use that may trigger psoriasis.

AIM

To minimize the triggering drug use and help the medical treatment of psoriasis patients.

MATERIAL AND METHODS

The study involved 289 psoriatic patients who attended our clinic in 2010-2012 and were asked to bring their drug lists of the last year, which they obtained from the pharmacy's record system. They were advised not to use the drugs that may trigger psoriasis. Data analyses were performed using SPSS program version 19.0.

RESULTS

A total of 289 patients were included in the study. Two hundred and twenty-one patients were using non-steroidal anti-inflammatory drugs; 133 patients were using anti-reflux drugs; 35 patients were using antidiabetic drugs; 31 patients were using calcium-channel blockers and 24 patients were using β-blockers. In our study group, there was no significantly difference between median PASI scores of the patients using a triggering drug and those of who are not using a triggering drug. However, there was a positive low correlation between PASI rates and numbers of drugs used (r = 0.180, p = 0.013).

CONCLUSIONS

Many other factors may trigger psoriasis, therefore the effect of stopping or minimizing the drug use on disease remission is not known. Because of the high triggering drug use rate, it is important to enlighten psoriasis patients about triggering drugs.

Calcium/calmodulin dependent kinase II contributes to persistent central neuropathic pain following spinal cord injury

Chronic central neuropathic pain after central nervous system injuries remains refractory to therapeutic interventions. A novel approach would be to target key intracellular signaling proteins that are known to contribute to continued activation by phosphorylation of kinases, transcription factors, and/or receptors that contribute to changes in membrane excitability. We demonstrate that one signaling kinase, calcium/calmodulin-dependent kinase II (CaMKII), is critical in maintaining aberrant dorsal horn neuron hyperexcitability in the neuropathic pain condition after spinal cord injury (SCI). After contusion SCI at spinal level T10, activated CaMKII (phosphorylated, pCaMKII) expression is significantly upregulated in the T7/8 spinal dorsal horn in neurons, but not glial cells, and in oligodendrocytes in the dorsal column in the same rats that displayed at-level mechanical allodynia. Furthermore, identified spinothalamic neurons demonstrated significant increases of pCaMKII after SCI compared to sham-treated control animals. However, neither astrocytes nor microglia showed pCaMKII expression in either sham-treated or SCI rats. To demonstrate causality, treatment of SCI rats with KN-93, which prevents CaMKII activation, significantly attenuated at-level mechanical allodynia and aberrant wide dynamic range neuronal activity evoked by brush, pressure, and pinch stimuli and a graded series of von Frey stimuli, respectively. Persistent CaMKII activation contributes to chronic central neuropathic pain by mechanisms that involve maintained hyperexcitability of wide dynamic range dorsal horn neurons. Furthermore, targeting key signaling proteins is a novel, useful therapeutic strategy for treating chronic central neuropathic pain.

Drug-Induced Psoriasis: An Evidence-Based Overview and the Introduction of Psoriatic Drug Eruption Probability Score

Psoriasis is a common skin disorder that needs a long-term management, not only because, of its prevalence but also because of the profound impact it can have on patients quality of life. Drugs may result in exacerbation of a preexisting psoriasis, in induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or in precipitation of the disease in persons without family history of psoriasis or in predisposed individuals. The knowledge of the drugs that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. By reviewing the literature, there are many reports on drug-induced psoriasis, but the data are not univocal. We propose, when possible, the use of a probability score from the authors to obtain a better classification and further understanding of drug-induced psoriasis.

Chronic medication use and inflammatory skin diseases: the power and limitations of the case-control study

The potential of newly introduced medications to cause acute inflammatory skin diseases has long been recognized. Less well accepted and not often systematically studied is the role of long-term drug use in inflammatory skin diseases such as eczema. Hypothesis-driven case-control studies provide what is probably the most efficient but far from easy method to evaluate and quantify observations from case reports and case series that suggest a drug etiology for chronic skin diseases.

Cutaneous reactions due to diltiazem and cross reactivity with other calcium channel blockers

BACKGROUND

The spectrum of cutaneous eruptions in association with calcium channel blockers is extensive, varying from exanthemas to severe adverse events. Reactions due to diltiazem occur more frequently than with other calcium channel blockers. Patch testing has been used as confirmatory testing in patients with extensive cutaneous reactions. Cross-reactivity among these drugs have not been established.

MATERIAL

We present 3 patients: 1) A 54-year-old man developed a generalized erythema-multiforme-like reaction followed by erythrodermia and exfoliative dermatitis 6-7 days after starting on diltiazem. The drug was stopped and remission was obtained with emollients and systemic corticosteroids and antihistamines within 12 days. 2) A 80-year-old woman experienced a pruritic exanthematous eruption on her trunk which evolved to generalized erythrodermia and superficial desquamation. This reaction appeared 10 days after taking diltiazem, and gradually improved in 10-12 days after discontinuation of this drug. 3) A 79-year-old man presented with erythema and pruritus initially on the back, and then affecting thorax, extremities and face. He had started treatment with diltiazem three days before. Diltiazem was stopped and steroid and antihistamine therapy was given. His skin condition improved, but 3 days later the patient received verapamil with worsening of previous situation. He recovered within 7 days.

METHODS AND RESULTS

Two to six months after the reaction, we carried out epicutaneous tests with calcium channel blockers from different groups. Diltiazem proved positive (at 48 and 96 hours) in the three patients; nifedipine was also positive in patient 2, and verapamil in patient 3. Controlled administration of verapamil was well tolerated in patient 2 after the reaction, and the patient 1 has taken nifedipine without problems.

CONCLUSIONS

1) We report 3 cases of cutaneous reactions due to diltiazem. 2) Epicutaneous tests have been useful for diagnosis. 3) As one of patients had positive patch tests to diltiazem and nifedipine, and other one with diltiazem and verapamil, more studies are needed to demonstrate cross reactions among calcium channel blockers.

Drug bioactivation, covalent binding to target proteins and toxicity relevance

A number of therapeutic drugs with different structures and mechanisms of action have been reported to undergo metabolic activation by Phase I or Phase II drug-metabolizing enzymes. The bioactivation gives rise to reactive metabolites/intermediates, which readily confer covalent binding to various target proteins by nucleophilic substitution and/or Schiff's base mechanism. These drugs include analgesics (e.g., acetaminophen), antibacterial agents (e.g., sulfonamides and macrolide antibiotics), anticancer drugs (e.g., irinotecan), antiepileptic drugs (e.g., carbamazepine), anti-HIV agents (e.g., ritonavir), antipsychotics (e.g., clozapine), cardiovascular drugs (e.g., procainamide and hydralazine), immunosupressants (e.g., cyclosporine A), inhalational anesthetics (e.g., halothane), nonsteroidal anti-inflammatory drugs (NSAIDSs) (e.g., diclofenac), and steroids and their receptor modulators (e.g., estrogens and tamoxifen). Some herbal and dietary constituents are also bioactivated to reactive metabolites capable of binding covalently and inactivating cytochrome P450s (CYPs). A number of important target proteins of drugs have been identified by mass spectrometric techniques and proteomic approaches. The covalent binding and formation of drug-protein adducts are generally considered to be related to drug toxicity, and selective protein covalent binding by drug metabolites may lead to selective organ toxicity. However, the mechanisms involved in the protein adduct-induced toxicity are largely undefined, although it has been suggested that drug-protein adducts may cause toxicity either through impairing physiological functions of the modified proteins or through immune-mediated mechanisms. In addition, mechanism-based inhibition of CYPs may result in toxic drug-drug interactions. The clinical consequences of drug bioactivation and covalent binding to proteins are unpredictable, depending on many factors that are associated with the administered drugs and patients. Further studies using proteomic and genomic approaches with high throughput capacity are needed to identify the protein targets of reactive drug metabolites, and to elucidate the structure-activity relationships of drug's covalent binding to proteins and their clinical outcomes.

Calcium: a potential central regulator in wound healing in the skin

Calcium has an established role in the normal homeostasis of mammalian skin and serves as a modulator in keratinocyte proliferation and differentiation. Gradients of calcium concentration increasing from 0.5 mM in the basal layer to > 1.4 mM in the stratum granulosum are consistent with migration patterns in response to minor abrasion (normal wear). Dermal fibroblasts require calcium but are approximately 100 times less sensitive than keratinocytes. Normal calcium metabolism in the skin is dependent on cell membrane and cytosolic calcium binding proteins (calmodulin, cadherins, etc.), but their modulation through parathyroid hormone, vitamin D or growth factors in normal or damaged tissue is not well documented. In wound repair, calcium is predominantly involved as Factor IV in the hemostatic phase, but it is expected to be required in epidermal cell migration and regeneration patterns in later stages of healing. Calcium alginate dressings are designed to liberate calcium early in the acute phase to promote hemostasis, but it is presently unclear whether the supplementary calcium influences the intracellular environment at later stages of wound repair, notably during the remodeling phase. Although experimental studies suggest that control of calcium is obligatory in wound management, we know very little as to how calcium in the wound bed is modulated through hormones, vitamin D, or various growth factors. Also, there is limited information as to how calcium released either from dressings, platelets, or from the circulation through the action of parathyroid hormone, growth factors or other modulators influences cell migration and remodeling in skin wounds, although experimental models suggest that management of calcium is essential in wound management.

Adverse dermatologic effects of cardiovascular drug therapy: part II

Cardiovascular disease is common, affecting an increasing number of persons as the population ages. To combat this growing health problem, physicians use a multitude of medications in the treatment of their patients. Although pharmacologic therapy greatly enhances quality of life for a majority of patients, there is always the potential for an unfavorable reaction. For example, cardiovascular drugs can induce a vast array of adverse dermatologic responses. This article reviews the various cutaneous reaction patterns that can occur as a result of treatment with class III, IV, and other antiarrhythmic agents, ACE inhibitors, Angiotensin II receptor blockers, and diuretics.

Selected drug complications and treatment conflicts in the presence of coexistent diseases

The presence of different coexistent systemic diseases often times complicates the selection of the appropriate treatment of an underlying rheumatologic condition. In this article, some controversial treatment conflicts that are frequently encountered in the daily practice of rheumatology are clarified and guidelines for the best available therapeutic options are provided.

The spectrum of cutaneous reactions associated with diltiazem: three cases and a review of the literature

BACKGROUND

Cutaneous reactions ranging from exanthems to severe adverse events have been reported in association with calcium channel blockers.

OBJECTIVE

Our purpose was to document cutaneous eruptions resulting from use of diltiazem.

METHODS

We describe three patients who experienced a cutaneous reaction (i.e., hypersensitivity syndrome reaction, pruritic exanthematous eruption, and acute generalized exanthematous pustulosis) possibly induced by diltiazem, summarize adverse reaction reports obtained from the Health Protection Branch, and review the literature on calcium channel blockers inducing cutaneous reactions.

RESULTS

Of the 315 cases of possible diltiazem-induced adverse reactions that were reported to the Health Protection Branch, 151 (48%) were cutaneous. The number of diltiazem-induced cutaneous events was significantly greater than those induced by either nifedipine or verapamil. However, no difference was found in the proportion of serious cutaneous adverse events to either of the three drugs.

CONCLUSION

Diltiazem has been associated with a variety of cutaneous reactions that appear to occur more frequently than with other calcium channel blockers.

Exfoliative dermatitis associated with diltiazem

BACKGROUND

Exfoliative dermatitis due to calcium channel blockers is a known but infrequent response.

CASE REPORT

A 77-year-old woman began treatment with diltiazem for angina pectoris. Three days later, severe exfoliative dermatitis developed.

CONCLUSION

The present case and the others previously reported emphasize the need for greater awareness of the occurrence of adverse cutaneous reactions including toxic epidermal necrolysis, Stevens-Johnson syndrome and cutaneous vasculitis due to calcium channel blockers including diltiazem.

Psoriasis: changing clinical patterns

Although psoriasis has been recognized at least since Biblical times new forms, associations and influences continue to be described in the twentieth century. New forms include the rupioid erythema annulare centrifugum-like and follicular patterns. Associations with vitiligo bullous pemphigoid and lupus erythematosus have been recently described. Endoscopic surgery has increased para umbilical psoriasis while Sun Smart campaign have reduced photo-aggravated psoriasis. Infections such as paediatric perianal streptococcal cellulitis and drugs including angiotensin converting enzyme inhibitors and cytokines exacerbate psoriasis.