Psoriasis during therapy with olanzapine

ARTICLE

Auteur(s) : Alessandra LATINI, Massimo CARDUCCI

Dipartimento di Dermatologia Infiammatoria, Polo Dermatologico S. Gallicano (IRCCS) Via Elio Chianesi, 53, 00144 Roma, Italy

Article accepted on 24/04/2003

Several studies have shown the role of different drugs in the onset or exacerbation of psoriasis, particularly in patients with a previous diagnosis or a family history of the disease. Many drugs may be responsible for inducing or triggering psoriasis, in particular betablockers, clonidine, digoxin, non steroidal anti-inflammatory agents, interferon and tetracyclines [1-3]. 
In addition, worsening of the clinical course of psoriasis has been described in patients treated with antimalarial agents [4] and anti-psychotic drugs. The role of lithium [5, 6] in triggering psoriasis is well known, but also other drugs used in psychiatry (such as bupropion) can induce the appearance of psoriatic lesions [7]. Recently, a few reports have described the cutaneous side effects induced by a new anti-psychotic drug, olanzapine [8, 9]. Olanzapine is a serotonin-dopamine receptor antagonist successfully used for treating negative and positive schizophrenic symptoms because of its reduced extra-pyramidal side-effects compared to other anti-psychotic drugs. Minor side-effects in the course of olanzapine therapy have been described, such as weight gain, sedation, dry mouth [10, 11] or, rarely, hypersalivation [12]. The mechanism of action of olanzapine is complex and not yet completely understood. 
We report two cases of psoriasis that exacerbated or developed during treatment with olanzapine for schizophrenia.

Case report

Case 1

In January 2001 a 38-year-old male patient, affected by psychosis with schizophrenic symptoms, presented to our department with numerous large plaques of psoriasis which had spread over a few days to the whole body surface. From the age of 14 the patient had suffered from psoriasis that had been effectively controlled up to date using only topical drugs. The patient, who had no family history for psoriasis, had started a new anti-psychotic treatment based on olanzapine per os (5 mg twice a day) one month before. After the first two weeks of olanzapine treatment the psoriasis worsened, becoming widespread to the whole body surface and resistant to topical treatment. The therapy with olanzapine was promptly discontinued and another anti-psychotic drug (risperidone, 2 mg three times a day) was prescribed. Concomitantly, a systemic therapy with cyclosporine A (3 mg/kg/die) was started to control the psoriasis, with complete resolution of the lesions two months later. Cyclosporine A was then gradually reduced and completely stopped in one month. Six months later, because of a dramatic worsening of the patient’s psychiatric symptoms, psychiatrists re-started the therapy with olanzapine at the same dose as the previous regimen. Several plaque-type psoriatic lesions appeared again on the extensor surfaces of the limbs and on the sacral region 15 days after the onset of olanzapine therapy. Olanzapine was stopped and the psoriatic lesions were treated with a topical therapy (salicylic acid 10% plus clobetasol propionate, twice a day), with complete resolution within one month.

Case 2

In January 2002 a 28-year-old man with a diagnosis of psychosis from the age of 22 presented to our department with several psoriatic plaques which had recently appeared on the trunk and extensor surfaces of the upper and lower limbs. His familial medical history was positive for psoriasis (the father), but to date, the patient had not presented any clinical manifestation of psoriasis. The lesions had appeared 20 days after starting olanzapine (5 mg, twice a day) therapy for recurrent schizophrenic symptoms. After consulting with the psychiatrist the treatment with olanzapine was discontinued and a different anti-psychotic treatment (amitryptiline 10 mg plus perphenazine 2 mg, twice a day) was started. A topical treatment (salicylic acid 10% plus clobetasol propionate, twice a day) was prescribed for the cutaneous lesions which cleared within one month. No recurrence of psoriasis was observed at a three month follow-up.

Discussion

We report two cases of psoriasis in psychotic patients treated with olanzapine, a new anti-psychotic drug. In the first patient we observed an exacerbation of a pre-existing mild psoriasis after two weeks of olanzapine treatment, and a relapse, after the same latency time, following a new administration of the anti-psychotic drug. In the second patient, who had only a family history of the disease, psoriasis developed after three weeks of olanzapine treatment. Both patients suffered from the same clinical form of psoriasis (a large plaque psoriasis) which developed at a similar length of time after starting olanzapine (two to three weeks). In addition, both patients did not take other anti-psychotic drugs, such as lithium, known to induce or exacerbate psoriasis.
These observations indicate a strict association between olanzapine therapy and psoriasis. Nevertheless, due to the low number of cases of psoriasis related to olanzapine and the complex action of the drug, the cause-effect relationship is not certain, but highly probable. In the literature we have found two reports about cutaneous side effects of this drug, the first one describing the exacerbation of chronic large plaque psoriasis [8], and the second one a pustular eruption [9]. In both cases the mechanism of cutaneous lesion induction by olanzapine was unexplained.
The mechanism underlying psoriasis development/worsening during olanzapine therapy is not understood, but it might be related the anti-dopaminergic activity of olanzapine [13]. Other dopamine-antagonists used in psychiatry, such as bupropion, have been reported to induce/exacerbate dermatological diseases [7]. In particular, psoriasis worsening during bupropion therapy has been described and it has been hypothesized that this could be due to an idiosyncratic reaction rather than related to a pharmacological action [7].
Given the high prevalence of psychotic disorders and psoriasis in the general population we consider our observations worthy of reporting. Moreover, the increasing diffusion of anti-dopaminergic drugs, such as olanzapine, stresses the need to follow up patients, in particular those with a family or personal history of psoriasis. n

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