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A 70-year-old woman presented with multiple infiltrating, erythematous scaly plaques on her chest and back (Fig. 1a). She also had a personal history of xerostomia and xerophthalmia, but no other symptoms were reported. The differential diagnosis included CLE, pityriasis rosea, autoimmune bullous dermatosis, and contact dermatitis following external application of a homeopathic tincture to the affected areas. Her medical history revealed four new drugs; amiodarone (an anti-arrhythmic), torasemide (a loop diuretic), losartan (an angiotensin II antagonist – anti-hypertonic), and phenprocoumone (a vitamin K antagonist – anticoagulant), initiated 10 days before the appearance of the lesions, prescribed due to an aortic valve replacement operation with biological prosthesis. The patient was also on long-term medication with bisoprolol (a β-blocker) and acetylsalicylic acid. The specific laboratory investigation detected an antinuclear antibody titre of 1:1280 (normal < 1:160) anti-Ro/SS-A autoantibodies > 240 units/ml (normal < 10 units/ml) and circulating immune complexes 70.9 g/ml (normal < 45.0 g/ml). ds-DNA, anti-histone and anti-nucleosome antibodies, myoglobin, creatine kinase, transglutaminase and gliadin antibodies, as well as complement and antibodies characteristic for autoimmune bullous diseases, were either normal or negative. Skin biopsies demonstrated superficial interface dermatitis, thus subacute CLE (SCLE), lichenoid drug reaction and erythema exsudativum multiforme came into consideration histologically. However, the associated increase in dermal mucinous material following application of Alcian blue stain favoured LE, namely SCLE of papulosquamous (psoriasiform) form, according to the classification of Gilliam & Sontheimer (4). The medical history also revealed similar clinical signs in 2005, after administration of terbinafine because of a tinea. Laboratory investigation had also detected an increased antinuclear antibody (ANA) titre at that time (1:1280), along with an increased anti-SS-A antibody titre. After discontinuation of terbinafine the patient rapidly became symptom-free. At the current admission, the suspected drugs could not be discontinued or replaced, due to the recent aortic valve replacement operation. The patient was treated with oral chloroquine, 250 mg/day, and mild and potent topical corticosteroids and antiseptics. Three months later there was marked improvement of the skin lesions, but complete healing did not occur (Fig. 1b).

Recurrent Subacute Cutaneous Lupus Erythematosus Following Exposure to Different Drugs