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Psoriatic Exacerbation Associated With Insulin Therapy

¹ Massachusetts General Hospital Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts
² Boston Dermatology & Laser Center, Boston, Massachusetts
³ Section of Endocrinology and Diabetes, Newton-Wellesley Hospital, Newton, Massachusetts

Corresponding author: Allan F. Moore, MD, MGH Diabetes Center, Massachusetts General Hospital, 55 Staniford St., 3rd Floor, Boston, MA 02114. E-mail: afmoore{at}partners.org

We report the case of a 70-year-old male who presented with worsening psoriasis after initiating insulin therapy.

The patient, who had a 25-year history of type 2 diabetes with no complications and an A1C of 7.8%, took metformin for 20 years with stable umbilical psoriasis. He did not require psoriatic therapy before initiating insulin therapy.

In December 2006, the patient transitioned to glargine injections for a rising A1C. Two weeks later, psoriasis erupted on his abdomen and legs. He continued on glargine with persistent symptoms until a dermatology consultant began hydrocortisone cream in March 2007. He discontinued glargine in August 2007 with partial resolution and was transitioned to Neutral Protamine Hagedorn (NPH) insulin. Another, similar eruption occurred within one week. Again, his psoriasis abated after NPH was discontinued. Glargine was reinitiated in November 2007, and, again, his psoriasis worsened, this time affecting his abdomen, back, and neck.

The patient reported a history of hypertension and hypercholesterolemia. Medications he was taking included timolol, isosorbide mononitrate, valsartan, atorvastatin, and aspirin. He was a retired policeman who quit smoking in 1997 and imbibed alcohol weekly. Family history was significant for type 2 diabetes and psoriasis in multiple family members. Examination revealed a well-appearing man weighing 153 lbs (21 kg/m²). Irregularly distributed plaques of erythema, on a scale ranging from 1–3 cm, covered the torso and extremities. Skin biopsy was consistent with psoriasis. He transitioned off insulin and restarted metformin. His psoriasis slowly abated while off insulin therapy.

Elevated endogenous insulin levels have been associated with psoriatic exacerbation before, as in the case of a 56-year-old woman diagnosed with an insulinoma (1). Insulin-related psoriatic exacerbation has biological plausibility because insulin has mitogenic effects through insulin receptor signaling and insulin's binding to the insulin-like growth factor receptor, a ubiquitous receptor that promotes cell growth and keratinocyte proliferation, attachment, and migration (2). Growth hormone also has insulin-like properties and has been reported to cause psoriatic exacerbations (3). Other diabetes medications, including metformin (4) and glibenclamide (5), have also been associated with psoriatic exacerbations. While a similar effect of an insulin secretagogue is not surprising, its appearance after initiation of an insulin sensitizer remains unexplained.

In summary, we present a report of psoriatic exacerbation following insulin therapy. Insulin, other anabolic hormones including growth hormone, and certain hypoglycemic agents are important causes of worsening psoriasis.

References

1. Field S, Kelly G, Tobin AM, Barragry JM, Conlon KC, Kirby B: Severe deterioration of psoriasis due to an insulinoma. Clin Exp Dermatol 33:145–147, 2008[Medline]
   
2. Hyde C, Hollier B, Anderson A, Harkin D, Upton Z: Insulin-like growth factors (IGF) and IGF-binding proteins bound to vitronectin enhance keratinocyte protein synthesis and migration. J Invest Dermatol 122:1198–1206, 2004[Medline]
   
3. Pirgon O, Atabek ME, Sert A: Psoriasis following growth hormone therapy in a child. Ann Pharmacother 41:157–160, 2007[Abstract/Free Full Text]
   
4. Koca R, Altinyazar HC, Yenidunya S, Tekin NS: Psoriasiform drug eruption associated with metformin hydrochloride: a case report. Dermatology Online Journal 9:11, 2003
   
5. Goh CL: Psoriasiform drug eruption due to glibenclamide. Australas J Dermatol 28:30–32, 1987[Medline]
   

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This Article Extract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Moore, A. F. Articles by Abourizk, N. Search for Related Content PubMed PubMed Citation Articles by Moore, A. F. Articles by Abourizk, N. Social Bookmarking                What's this?