A rare case of apixaban-induced psoriasiform drug eruption: A case report

Dear Editor, Psoriasis is a chronic multifactorial disorder impacting approximately 0.6%–4.8% of the global population.[1] Its onset has been linked to many factors, such as smoking, psychological stress, physical trauma, infections, withdrawal of systemic corticosteroids, and certain drugs.[1] The recent increase in apixaban use has led to the discovery of a new incidence of cutaneous adverse reactions to this drug.[2] These adverse effects can result in substantial morbidity if not promptly recognized and managed.[2] Few than 1% of patients receiving apixaban treatment have documented incidences of skin rash and anaphylactic responses, such as angioedema.[3] We report the case of a 60-year-old male patient who was presented to our clinic with a history of venous thromboembolism. Twenty days after he had taken apixaban, he developed a pruritic rash all over the body. Skin examination revealed well-demarcated erythematous plaques with mildly thick scales on both elbows [Figure 1], proximal fingers, scalp, and nape of the neck [Figure 2]. There were thick scales on his palms. Slightly erythematous desquamative patches were seen on his face. There was no arthropathy, nail alterations, or ocular symptoms. There was no history of any chronic disease, metabolic syndrome, or COVID-19 infection. There was no history of recent vaccinations such as influenza or COVID-19 vaccination. Hematological examination including eosinophil absolute count was normal. Other routine investigations were within normal range, except hepatitis B surface antigen which was positive.Figure 1: Brownish scaly plaque on the elbow.Figure 2: Whitish scaly plaque on the nape of the neck extends to the occipital area with satellite erythematous papules.A diagnosis of apixaban-induced psoriasiform eruption was suggested. Apixaban was discontinued and replaced by warfarin. The patient was treated with topical Daivobet and mild-potency topical steroids. On follow-up, lesions were reduced with no evidence of new lesions, and the previous lesions were cleared within 6 months of apixaban withdrawal. Direct oral anticoagulants have represented more than 60% of all prescribed anticoagulants and displaced warfarin for the treatment of arterial fibrillation and venous thromboembolism. Hypersensitivity adverse drug events linked with anticoagulants are being more frequently documented in the literature.[2] Several cardiovascular drugs, such as beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and digoxin, have been implicated as potential culprits for psoriasiform drug eruptions in the literature.[1,3,4] Tumor necrosis factor-alpha inhibitors and sorafenib have also been linked to a few psoriasiform drug eruption cases.[1,4] On the other hand, apixaban has seldom been associated with psoriasiform eruptions.[3] Patil et al.[2] described a patient with atrial fibrillation on apixaban who had a lichenoid eruption that improved after he had stopped apixaban. The Naranjo score of his patient was 8 placing it within the “probable” causality category.[5] In previous literature, leukocytoclastic vasculitis was reported after taking apixaban and was resolved by discontinuation of the drug and the use of oral steroids.[6] In another case report, a palmoplantar psoriasiform eruption was observed in a patient after using apixaban, which improved gradually after drug withdrawal and the use of topical corticosteroids.[4] In our case, the patient has a negative history of psoriasis, psoriasis-causing drugs, or a family history of psoriasis. The lesions formed 20 days after the initiation of apixaban therapy and showed improvement with cessation of the medication and the use of topical steroids. The Naranjo score was 6, indicating that the cutaneous eruption was probably due to apixaban. Thus, based on our findings, it can be inferred that apixaban is a plausible cause of psoriasiform drug eruption in our patient. To conclude, an in-depth comprehension of drug-induced or drug-aggravated psoriasis can provide valuable insights for the optimal treatment of this condition. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Data availability statement All data generated or analyzed during this study are included in this published article. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.