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743nisolone (16 mg a day) therapy, 8 days later, rapid progression of the disease was detected associated with painful skin, fever and candidiasis of the corners of mouth. After raising methylprednisolone (32 mg a day) together with administration of ethacrynic acid (50 mg a day), skin symptoms progressed to erythroderma. In parallel, symptoms and signs of tetany appeared, calcium levels decreased to 1.1 mmol/L (normal range: 2.15-2.55); phosphate levels increased to 2.8 mmol/L (normal range: 0.81-1.62). After adequate calcium and dihydrotachysterol administration, serum calcium and phosphate levels normalized, but clinical improvement was only detected after methotrexate (7.5 mg a week) and methylprednisolone (80 mg a day) were given (etretinate was discontinued). Although later the dose of methylprednisolone and methotrexate could be reduced to 12 mg every second day and 2.5 mg every twelfth day, respectively, withdrawal of methotrexate resulted in recurrence of the pustular skin condition even when serum calcium levels were normal or higher than normal. After 2 years of this medication, repeated examinations revealed symptomless nephrolithiasis associated with intermittent pyuria. After successful extracorporeal shock-wave lithotripsy, she became completely free of skin symptoms, and after 3 years of followup, both methotrexate and methylprednisolone could be stopped. In the last year of follow-up, she had only very mild skin symptoms in the body folds on dihydrotachysterol monotherapy. Our case confirms previous observations that impetigo herpetiformis can occur in patients with hypoparathyroidism when calcium is insufficiently substituted. Latent ionized hypocalcaemia may have been present already at the time of admission, but it might also have been drug induced. Although acitretine is known to induce hypercalcaemia, both ethacrynic acid and methylprednisolone increase urinary calcium excretion, and methylprednisolone also decreases intestinal calcium absorption when given in pharmacologic doses. 4 In conclusion, laboratory examinations for both total and ionized serum calcium levels are recommended in all cases of pustular psoriasis. Hypocalcaemia might be, however, not the only provoking factor. Methotrexate was shown to be useful for additional treatment of impetigo herpetiformis.References 1 Hebra F. Über einzelne während der Schwangerschaft, dem Wochenbette und bei Uterinalkrankheiten der Frauen zu beobachtende Hautkrankheiten.
743nisolone (16 mg a day) therapy, 8 days later, rapid progression of the disease was detected associated with painful skin, fever and candidiasis of the corners of mouth. After raising methylprednisolone (32 mg a day) together with administration of ethacrynic acid (50 mg a day), skin symptoms progressed to erythroderma. In parallel, symptoms and signs of tetany appeared, calcium levels decreased to 1.1 mmol/L (normal range: 2.15-2.55); phosphate levels increased to 2.8 mmol/L (normal range: 0.81-1.62). After adequate calcium and dihydrotachysterol administration, serum calcium and phosphate levels normalized, but clinical improvement was only detected after methotrexate (7.5 mg a week) and methylprednisolone (80 mg a day) were given (etretinate was discontinued). Although later the dose of methylprednisolone and methotrexate could be reduced to 12 mg every second day and 2.5 mg every twelfth day, respectively, withdrawal of methotrexate resulted in recurrence of the pustular skin condition even when serum calcium levels were normal or higher than normal. After 2 years of this medication, repeated examinations revealed symptomless nephrolithiasis associated with intermittent pyuria. After successful extracorporeal shock-wave lithotripsy, she became completely free of skin symptoms, and after 3 years of followup, both methotrexate and methylprednisolone could be stopped. In the last year of follow-up, she had only very mild skin symptoms in the body folds on dihydrotachysterol monotherapy. Our case confirms previous observations that impetigo herpetiformis can occur in patients with hypoparathyroidism when calcium is insufficiently substituted. Latent ionized hypocalcaemia may have been present already at the time of admission, but it might also have been drug induced. Although acitretine is known to induce hypercalcaemia, both ethacrynic acid and methylprednisolone increase urinary calcium excretion, and methylprednisolone also decreases intestinal calcium absorption when given in pharmacologic doses. 4 In conclusion, laboratory examinations for both total and ionized serum calcium levels are recommended in all cases of pustular psoriasis. Hypocalcaemia might be, however, not the only provoking factor. Methotrexate was shown to be useful for additional treatment of impetigo herpetiformis.References 1 Hebra F. Über einzelne während der Schwangerschaft, dem Wochenbette und bei Uterinalkrankheiten der Frauen zu beobachtende Hautkrankheiten.
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