Pemphigus foliaceus induced by an angiotensin II receptor blocker

A 76-year-old Korean woman presented with pruritic erythematous vesicles and crusted plaques over her entire body. She had been taking an angiotensin II receptor blocker (ARB) (candesartan) for 2 months before developing the skin lesions. The patients was diagnosed with pemphigus foliaceus based on the clinical and immunopathological criteria, including intra-epidermal bulla on skin histopathology, intercellular deposit of C(3) and IgG on direct immunofluorescence, and autoantibodies to the 160-kDa antigen on both immunoblot and ELISA. The medication was changed to another antihypertensive agent and the patient was treated with prednisolone for 2 months. The vesiculobullous skin lesions gradually disappeared. However, the skin lesions reappeared 2 months after starting a different ARB (telmisartan). This case illustrates the importance of taking a complete drug history in patients who present with bullous diseases. Furthermore, ARBs should be added to the list of nonthiol drugs that can possibly induce pemphigus.