Adverse reaction to the beta-adrenergic blocking drugs

Drugs in exacerbation of psoriasis

Drugs that have been associated with the precipitation or exacerbation of psoriasis include lithium, beta adrenergic receptor blocking agents, and antimalarials. The withdrawal of corticosteroids has been reported to activate pustular psoriasis. Nonsteroidal anti-inflammatory drugs, such as indomethacin, have recently been reported to exacerbate psoriasis, although additional well-controlled studies are still needed. Drugs used for treatment of psoriasis will sometimes cause a flare because of irritation, phototoxicity, or hypersensitivity reaction resulting in a Koebner phenomenon. Because psoriasis is a very complex disease and its activity is often unpredictable, clinical studies on adverse drug effects on psoriasis have been difficult to conduct. This review evaluates clinical, histologic, and biochemical evidence in the literature for drug-associated onset or exacerbation of psoriasis.

A new concept in the pathogenesis of drug-induced psoriasis

Since drug-induced psoriasis is triggered by a known agent, studies of this type of psoriasis may provide clues to understanding the pathogenesis of the disease. Analysis of the reported cases of drug-induced psoriasis lead us to the postulation of a new concept of this disease. According to this concept drug-induced psoriasis is an auto-immune disease of the beta receptors of the skin. The initial and central event is the alteration of the immunological properties of the receptor due to an interaction with the drug. This leads further to the activation of an immunological cascade that results in a reduction in the functional activity of the receptors and through a known pathway to the development of the clinical manifestation of the disease.

Inhibition of a Langerhans cell-mediated immune response by treatment modalities useful in psoriasis

Neither the pathogenesis of psoriasis nor the mechanism whereby seemingly diverse therapies alter the disease is understood. In this study, several antipsoriatic agents were tested for their effects on the skin cell lymphocyte reaction (SLR), an immunologic assay in which HLA-DR antigens on Langerhans cells (LC) stimulate proliferation of allogeneic lymphocytes. Every agent tested (cortisol, methotrexate, hyperthermia, anthralin) inhibited the SLR at therapeutic dose levels. By contrast, a variety of antibiotics, an anti-inflammatory agent, and lithium carbonate and propranolol, two drugs known to be ineffective in psoriasis, failed to inhibit the SLR. Finally, we have shown that hyperthermia and anthralin treatments are toxic for LC whereas they have little or no effect on keratinocyte viability. These results suggest that antipsoriatic agents may act in psoriasis by alteration or killing of LC.

Characterization of alpha- and beta-adrenergic agonist stimulation of adenylate cyclase activity in human epidermal keratinocytes in vitro

Adrenergic receptors are responsible for selective recognition and binding of catecholamines and may in turn have an effect on epidermal cell growth and maturation via adenosine-3',5'-monophosphate (cAMP). Using endogenous catecholamines and drugs specific for alpha- and beta-receptor subtypes, we have characterized the adrenergic receptor coupled to adenylate cyclase in cultured human epidermal keratinocytes. The relative potency order of stimulation of adenylate cyclase was: isoproterenol greater than epinephrine much greater than norepinephrine. The predominant adrenergic receptor is of the beta 2-subtype, as also confirmed by use of the selective antagonists propranolol, butoxamine, and atenolol. No evidence of alpha-adrenergic receptor mediation of adenylate cyclase was noted with the alpha 2-specific agonist, clonidine. Phenylephrine, the alpha 1-specific agonist, affected cAMP formation but this response could not be totally inhibited with prazosin, suggesting an unknown mechanism of action. Human keratinocytes retained the same beta-adrenergic receptor potency order properties throughout growth and maturation.

Effect of beta-adrenergic receptor blockade or refractoriness induced by isoproterenol on growth of keratinocytes in vitro

Almost complete suppression of beta-adrenergic sensitivity of adenylate cyclase was produced in keratinocytes growing on collagen gels either by induction of refractoriness by isoproterenol or by receptor blockade by propranolol, these drugs being introduced 3 days post-plating and continuously thereafter. Neither of these two manoeuvres affected growth of the keratinocytes. Despite this suppression, basal levels of cyclic AMP never fall below the levels observed in untreated cultures. On the other hand, growth inhibition is observed if isoproterenol or propranolol is added on plating. When keratinocytes are seeded on 3T3 fibroblast feeder layers, isoproterenol enhances colony growth, as reported elsewhere, indicating that the effects of isoproterenol are therefore modulated by the culture surface. In either of these in vitro model systems studied (collagen or feeder layers), no mechanism was obvious that would account for propranolol-induced psoriasiform lesions observed in vivo.

Induced pemphigus

The reports of induced pemphigus have multiplied over the last 10 years. Several heterogeneous factors, such as drugs (penicillamine, pyritinol, captopril, rifampicin, etc.), physical agents (burns, UV, and ionizing radiation) and viruses, can play an inducing role. Usually, the disease is preceded by prodromal, non-specific lesions. The full-blown stage shows features of pemphigus foliaceus, erythematosus or herpetiformis. Histologically, acantholytic splits mostly occur at the highest malpighian layers. Intercellular antibodies and frequently concomitant other auto-antibodies are found in the serum, the titre of the former usually being low and unrelated to the severity or course of the disease. The biological progress is variable and ranges from rapidly and definitively healing cases (induced pemphigus proper) to others which, in spite of the elimination of the inducing factor, self perpetuate just like true pemphigus (triggered pemphigus). Pathogenic hypotheses are based on the act that some inducing factors can alter the antigen distribution on keratinocyte membranes and/or interfere with immune surveillance by impairing T-suppressor cells.

Contact eczema produced by a beta-adrenergic blocking agent (alprenolol)

In a pharmaceutical industry, several cases of allergic contact eczema caused by the beta-adrenergic blocking agent alprenolol (Aptin) have appeared. This report deals with 12 men and two women who developed eczema during work with the substance. In 13 of the 14 cases, the induction time for sensitization was less than 1 year. The skin reactions were very florid. After healing they could be reproduced by very small quantities of the substance. In one case, eczema could also be produced after ingestion of Aptin tablets. All the cases were transferred to other work within the factory. An intensive programme was implemented to remove dust from the working areas. Despite this, isolated new cases still appear. Some employees in contact with the substance also experienced mucous membrane symptoms. These symptoms could not be shown to have an allergic aetiology, but were considered to be irritant reactions. Alprenolol must be considered a very strong contact allergen.