Generalized pustular psoriasis (von Zumbusch) following iatrogenic hypocortisolism

Generalized pustular psoriasis can be triggered by hypocalcemia, pregnancy, stress and drugs but frequently has no obvious cause. We report a case which was only cured after treatment of iatrogenic adrenal axis suppression. A 41 year old woman had been suffering for nine months from a generalized pustular psoriasis which had occurred after a three week topical corticosteroid therapy of plaque psoriasis with 90 g of betamethasone dipropionate + 2% salicylic acid. Successive systemic treatments failed but topical corticosteroids brought relief to the patient. Cortisol level was found to be very low. Further investigations showed iatrogenic adrenal axis suppression. Hydrocortisone supplementation brought spectacular improvement and complete healing in a few months.We suggest that our patient was extremely sensitive to corticosteroids because the first pustules appeared after a conventional topical treatment. Adrenal axis suppression has never been involved in the aggravation of inflammatory dermatoses except in two cases of severe atopic dermatitis. Endogen corticosteroids inhibit proinflammatory cytokines by a feed-back mechanism and might have a great importance in the immune regulation loop. Cortisol level measurement should be considered in corticodependent inflammatory dermatoses.