==== Front Chin Med J (Engl)Chin. Med. JCMJChinese Medical Journal0366-6999Medknow Publications & Media Pvt Ltd India CMJ-131-188710.4103/0366-6999.237411CorrespondenceHydroxychloroquine-Induced Psoriasis-form Erythroderma in a Patient with Systemic Lupus Erythematosus Wang Wen-Ming 1Wang Kevin Yu 2Wang Tao 1Jin Hong-Zhong 1Fang Kai 11 Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China2 State University of New York Upstate Medical University, Syracuse, NY 13210, USAAddress for correspondence: Dr. Tao Wang, Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China E-Mail: tombearwt@126.com05 8 2018 131 15 1887 1888 18 4 2018 Copyright: © 2018 Chinese Medical Journal2018This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. ==== Body To the Editor: Hydroxychloroquine (HCQ) is commonly used in systemic lupus erythematosus (SLE), rheumatoid arthritis, and other autoimmune disorders. We report a case of psoriasis-form erythroderma induced by HCQ in an SLE patient. Thus, rheumatologists and dermatologists should be aware of the possibility of HCQ-induced psoriasis-form lesions. A 41-year-old woman was admitted to our clinic with new onset SLE. There was no history of psoriasis in the patient or her immediate family. She was prescribed HCQ (200 mg twice daily) and prednisone (30 mg once daily). After 2 months of treatment, the patient presented with diffuse erythema and scaling involving the entire body, HCQ was withdrawn, and prednisone was increased to 60 mg once daily. Physical examination showed erythroderma involving approximately 100% of her body surface area with a Psoriasis Area and Severity Index score of 61.2 [Figure 1a and 1b]. The toenails were yellow and showed hyperkeratosis with thickened nail plates [Figure 1c]. Laboratory findings showed leukocytosis (white blood cell [WBC] count 19.97 × 109/L with 16.42 × 109/L neutrophil granulocytes), hemoglobin 12.4 g/dl, platelet count 525 × 109/L, alanine aminotransferase 43 U/L, aspartate aminotransferase 21 U/L, hs-CRP 52.05 mg/L, ESR 36 mm/h, and PCT 0.5 ng/ml. Antinuclear antibody (+1:320), anti-Rib, and anti-histone antibodies were positive. Alopecia, decreased WBC (3.3 × 109/L), C3 (0.896 g/L), and C4 (0.093 g/L), and positive urinary protein had appeared over the course of the disease. Histopathologic findings revealed parakeratosis, acanthosis cell layer thickening, irregular elongation of rete ridges, dilated dermal blood vessels, and perivascular lymphomonocytic infiltration in the dermis [Figure 1d]. This patient had no previous history of psoriasis; lesions appeared after HCQ was given and receded when HCQ withdrawn. Punch biopsy showed psoriasis-form dermatitis, and a diagnosis of erythrodermic psoriasis was established. The patient was started on tripterygium glycoside (20 mg three times daily) and showed improvement of skin lesions within 2 weeks. Figure 1 Clinical and histopathology characteristics. (a and b) Erythema on approximately 100% body surface area. (c) Toenails were yellow and showed hyperkeratosis with thickened nail plates. (d) Parakeratosis, acanthosis cell layer thickening, irregular elongation of rete ridges, dilated dermal blood vessels, and perivascular lymphomonocytic infiltrations in the dermis (H and E). Psoriasis is a chronic inflammatory skin disease most commonly characterized by well-demarcated, erythematous plaques with silvery scales. Common drugs used to treat psoriasis include lithium, antimalarials, beta blockers, and others. HCQ is an antimalarial agent. The reported effects of antimalarials include antimicrobial, antithrombotic, metabolic and cardiovascular, antineoplastic, and others. The main adverse effects of HCQ include retinopathy, cardiomyopathy, pigmentation changes, and aplastic anemia. Case studies have reported a possible association between HCQ and the induction or exacerbation of psoriasis. HCQ accumulates in varying concentrations in different tissues. High concentrations are found in eye, skin, cardiac tissues, and so on.[1] These high concentrations may play a crucial role in the development of HCQ-induced psoriasis-form erythroderma. Clinically, it is difficult to discern the difference between HCQ-induced psoriasis-like erythroderma and drug-induced hypersensitivity. Drug-induced hypersensitivity has more eosinophil infiltration, and the exfoliation of the epidermis is more intense compared with psoriasis-like erythroderma. Our patient was characterized by erythroderma with large scales, no Beau's line, and pathological lack of eosinophils. Therefore, we believed the patient had HCQ-induced psoriasis-form erythroderma.[2] The coexistence of psoriasis and SLE is very uncommon and needs specific therapeutic solutions. A single-center experience showed that the prevalence of psoriasis in SLE was twice as high as that of the general Canadian population.[3] Previous studies revealed that psoriasis and SLE share two SNPs (rs8016947 and rs4649203) and both results in elevated levels of interleukin (IL)-17, IL-23, and IL-12.[45] Herein, we present a case of HCQ related psoriasis-form erythroderma in a patient with SLE. HCQ is a commonly used agent for dermatologic and rheumatologic conditions. HCQ may induce or exacerbate the psoriasis. Withdrawal of systemic corticosteroids raises the risk of severe psoriasis relapse. Tripterygium glycoside is widely used in the treatment of psoriasis, SLE, and other inflammatory conditions. We treated this patient with tripterygium glycoside, which resulted in improvement of skin lesions. This case demonstrates that HCQ should be added to the list of medications that potentially induce psoriasis-form erythroderma. Declaration of patient consent All appropriate patient consent forms were obtained, the patient gave consent for images and other clinical information to be reported. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship This study was supported by grants from CAMS Initiative for Innovative Medicine (No. 2017-I2M-B&R-01) and the Teaching Reform project of Peking Union Medical College (No. 2014zlgc0102). Conflicts of interest There are no conflicts of interest. Edited by: Ning-Ning Wang ==== Refs REFERENCES 1 Yogasundaram H Putko BN Tien J Paterson DI Cujec B Ringrose J Hydroxychloroquine-induced cardiomyopathy: Case report, pathophysiology, diagnosis, and treatment Can J Cardiol 2014 30 1706 15 doi: 10.1016/j.cjca.2014.08.016 25475472 2 Tsutsumi R Yoshida Y Yamamoto O Imiquimod-induced psoriatic erythroderma treated with infliximab Acta Derm Venereol 2017 97 279 80 doi: 10.2340/00015555-2495 27349505 3 Tselios K Yap KS Pakchotanon R Polachek A Su J Urowitz MB Psoriasis in systemic lupus erythematosus: A single-center experience Clin Rheumatol 2017 36 879 84 doi: 10.1007/s10067-017-3566-0 28168661 4 Li Y Cheng H Zuo XB Sheng YJ Zhou FS Tang XF Association analyses identifying two common susceptibility loci shared by psoriasis and systemic lupus erythematosus in the Chinese Han population J Med Genet 2013 50 812 8 doi: 10.1136/jmedgenet-2013-101787 24070858 5 Varada S Gottlieb AB Merola JF Saraiya AR Tintle SJ Treatment of coexistent psoriasis and lupus erythematosus J Am Acad Dermatol 2015 72 253 60 doi: 10.1016/j.jaad.2014.10.038 25486913