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Author: Dr Hyun Kyoung Lee, Medical Registrar (2023). Reviewing dermatologist: Dr Ian Coulson
Edited by the DermNet content department
A 23-year-old female presents with a six-week history of an erythematous rash starting around the feet then spreading cephalically until covering 60% of the skin surface, predominantly over the torso.
The patient started lamotrigine two months prior to presentation and the dose slowly uptitrated for epilepsy control.
A biopsy showed subcorneal pustules; direct immunofluorescence was negative.
There is a patchy and confluent erythematous rash studded with fine pseudo pustules and peripheral circular peeling seen over the abdomen.
The likely cause is lamotrigine-induced generalised pustular psoriasis (GPP). Lamotrigine is a widely used antiepileptic commonly producing cutaneous side effects (incidence 10%). However, this is the first report of lamotrigine-induced GPP.
Other differential diagnoses would include:
After stopping the offending drug (lamotrigine in this case), the first-line treatment for generalised pustular psoriasis (GPP) would include acitretin, ciclosporin, or methotrexate. If this is insufficient, a biologic agent could be considered.
It is important to note that glucocorticosteroids typically flare pustular psoriasis, particularly on withdrawal, so are contraindicated for GPP.