Ramipril-induced generalized pustular psoriasis: case report and literature review

Mrs. M.S. is a 67-year-old African American woman with a history of rheumatoid arthritis and psoriatic arthritis who presented to the emergency room with complaint of new-onset rash, chills, and fatigue after she started taking ramipril (5 mg orally every day) for her hypertension. The rash involved entire upper chest, both arms, palms, and soles and was characterized as exfoliating with scattered small pustules of 1-2 mm in size. Patient was admitted with a differential diagnosis of exfoliative dermatitis versus adverse drug reaction for which her ramipril was stopped. After admission, the patient spiked a temperature of 102 degrees F with chills, the entire workup for which was negative, including blood cultures, chest x-ray, and urine analysis. She underwent skin biopsy to find the cause of her rash. With her given clinical characteristics, she was presumed to have generalized pustular psoriasis (GPP), which was later confirmed by biopsy results. She was treated with methylprednisolone to which she responded dramatically with much improvement in her rash and her fever subsided. The flare of GPP was considered to be secondary to ramipril. After reviewing the published literature, there are no published cases of ramipril-induced GPP. Captopril, a different angiotensin converting enzyme (ACE) inhibitor, is known to cause flare of GPP. We presented this case as apart from being the first reported case of ramipril-induced GPP; clinicians and dermatologist should also be aware of this potentially serious complication of psoriasis when they start ramipril in patients with psoriasis.