A 28‐year‐old Caucasian woman presented with erythematous macules, patches, and scaly plaques that were occasionally pruritic and painful. Areas affected were the axillae, breasts, and groin. The patient's breasts and thighs exhibited signs of striae formation, one of the features of Cushing's syndrome.1 Ten years earlier, subcorneal pustular dermatosis (SCPD) was diagnosed; however, she claimed that symptoms first appeared when she was 3 years old. Symptoms waxed and waned throughout her life but had begun to progressively worsen. Overall, she was well‐adjusted, having lived with the dermatosis for her entire life; however, the location of the rash and the associated pruritus interfered with sexual intimacy, occasionally causing her to become depressed. She reported no other systemic symptoms other than mild, morning joint stiffness, and no comorbidities were detected. Family history was negative for dermatologic disease. At presentation, results from the complete blood cell count, serum protein electrophoresis, and urine protein electrophoresis were all within normal limits. There were no visible pustules on presentation, but there were subclinical pustules on biopsy, confirming the diagnosis of moderate to severe SCPD. Pathology analysis revealed subcorneal and intraepidermal vesiculopustule formation with abundant neutrophils and a dermal superficial perivascular inflammatory infiltrate (Figure). Immunoglobulin (Ig)A pemphigus was ruled out since direct immunofluorescence was negative for all immunoreactants, including IgA, IgG, IgM, C1q, C3, C4, and fibrinogen with albumin as a control. Figure Photomicrograph of subcorneal pustular dermatosis. A large pustule is seen beneath the stratum corneum. Arrow indicates neutrophils on epidermal surface (hematoxylin and eosin stain, original magnification ×20). Past therapy included numerous topical steroidal treatments in addition to nonsteroidal treatments such as calcipotriol. At presentation, the patient was taking oral dapsone (75 mg alternating with 100 mg/d). Dapsone has long been considered the treatment of choice for SCPD,2 but it had been ineffective at this dosage, and the patient had experienced 2 of its well‐known side effects: hemolytic anemia and peripheral neuropathy.3 A test for glucose‐6‐phosphate dehydrogenase deficiency, which can cause hemolytic anemia, was done before dapsone therapy and results were negative. Treatment was initiated with tetracycline (1000 mg bid), nicotinamide (500 mg bid), and the nonsteroidal topical tacrolimus twice a day. Tetracycline was used because other inflammatory skin disorders, such as bullous pemphigoid, respond to the antibiotic with or without nicotinamide.4,5 Tetracycline was employed for 3.5 months, but failed to significantly reduce the signs and symptoms of the patient's disease. Alternative therapy was sought by changing topical tacrolimus to topical calcipotriol twice a day and adding the topical steroid 0.05% halobetasol propionate cream on weekends and 0.005% fluticasone propionate ointment Monday thro...
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