Sir,

A 62-year-old medical doctor consulted for lesions on the nails of his fingers and toes. A clinical examination revealed splinter hemorrhages on several nails of the fingers (Fig. 1a) and toes (Fig. 1b), which appeared two months prior to consultation. The clinical examination of the rest of the skin was unremarkable. Neither a history of psoriasis nor of atopy was reported by the patient. His family history was also negative for psoriasis as for autoimmunity. The patient had been taking an antihypertensive drug associating amlodipine (calcium channel blocker) and valsartan (angiotensin II receptor blocker) for the last ten years.

Figure 1: a) Splinter hemorrhages on the nail of the right thumb. b) Splinter hemorrhages on the nails of the toes.

Psoriasis is a chronic inflammatory skin condition, and its most common manifestation is erythematous plaques covered with white thick scales. Angiotensin II receptor blockers are related to the development of psoriasis, while calcium channel blockers are considered one of the most important psoriasis inducers. Nail involvement in psoriasis is common; it is seen in 80% of cases and may be the only manifestation in only 6% [1,2]. It includes onycholysis, pitting, subungual hyperkeratosis, red lunula, oil spots (salmon patch), nail dystrophy, leukonychia, and splinter hemorrhages [3]. A recent French study has investigated the psoriasis risk with calcium channel blocker exposure [4]. This study confirmed the risk of psoriasis associated with the intake of all calcium channel blockers. Time to onset was less than two years, with male predominance and a favorable outcome following the discontinuation of the drug. The author explained to the patient the nature of his lesions and the danger of developing psoriatic lesions elsewhere and advised him to switch to another class of antihypertensive medication, which the patient refused as his hypertension was well controlled. This case is reported to increase awareness about the possible early signs of drug-induced nail psoriasis.

REFERENCES

1.Canal-García E, Bosch-Amate X, Belinchón I, Puig L. Nail Psoriasis. Actas Dermosifiliogr. 2022;113:481-90.

2.Yesudian PD, de Berker DAR. Inflammatory nail conditions. Part 1:nail changes in psoriasis. Clin Exp Dermatol. 2021;46:9-15.

3.Muneer H, Sathe NC, Masood S. Nail Psoriasis. 2024 Mar 1. In:StatPearls [Internet]. Treasure Island (FL):StatPearls Publishing;2025 Jan–. PMID:32644686.

4.Azzouz B, Laugier-Castellan D, Sanchez-Pena P, Rouault M, Kanagaratnam L, Morel A, Trenque T. Calcium channel blocker exposure and psoriasis risk:Pharmacovigilance investigation and literature data. Therapie. 2021;76:5-11.