British journal of Dermatology (1992) 127.
fest within the setting of haemophilia A. Further detailed studies are in progress. The improvement in affect and self-confidence seen in this teenager was striking. It is well documented that acne impairs self-confidence'' and employment opportunities." These features are also recognized in haemophiliacs. Adequate treatment of acne is therefore particularly desirable in these patients. We would, however, recommend caution when using isotretinoin in patients with haemophilia until further detailed studies of fibrinolysis in vivo are available. Departments of Dermatology atid *Haematologii. Queen Elizabeth Hospital Kitig's Lynn. Norfolk PE3() 4ET. UK
G.M.DOOTSON J.KEIDAN* J.A.R.ANDbKSON
References 1 David M, Hodak K, [,owe NH. Adverse effects of retinoids. Med Toxicol Adverse Drug l-xp 1988; 3: 2 7 i - 8 8 . 2 lohnson TM. Rapini RP. Isotretinoin-induced thrombocytopfnia. I Am Acad Dermatol 1987: 17: S 58-9, } Hesdorffcr CS, Wcltman MD. Raftopouios H el a!. Thrombocytopenia caused by isotretinoin. S Afr Med / 1986; 70: 705-6. 4 Hamilton IA, Stimtilation of the plasminogen activator activity of human synovial fibroblasts by retinoids. Arthritis Rheimt 1 982; 25: 4i2-4(), 5 Bounameaux H. Reber G. Bounanicaux Y. Acute effects of retinoids on fibrinolysis before and after venous occlusion in healthy humans. ThrombRes 1988; 50: I7S-9. 6 )owett S, Ryan T. Skin disease and handicap: an anaiysis of the impact of skin conditions, Sov Sci Med 1985; 20: 425-9. 7 Ctinliffe W|. Acne and unemployment. Br j Dermato} 1986; 11 5: 386.
Generalized pustular psoriasis associated with bacterial endocarditis ofthe anterior papillary muscle SIR. Generalized pustular psoriasis (GPP) is an uncommon condition first described by von Zumbusch in 1910.' Exogenous precipitating factors are well recognized and include drugs, in particular a reduction in the dose of systemic or potent topical steroids.^ pregnancy,' sunburn.^ and infections.'' We report a case of GPP and bacterial endocarditis, an association which, to our knowledge, has not been described previously. This patient is of particular interest as the endocarditis affected the papillary muscle, a recognized but unusual phenomenon. A 24-year-old Moroccan man presented with a l-week history of a rash affecting the dorsa of his hands and feet. He gave a 20-year history of psoriasis affecting his scalp, arms and groins. He had used about 50 g of betamethasone dipropionate U 05% (Diprosone®) cream per week on the affected areas for many years, and 4 days before admission this had been changed to betamethasone valerate 0-1% cream in a 1 in 4 dilution (Betnovate RU®) which he had used sparingly. There was no history of rheumatic fever. On examination he was apyrexial. Tbere were erythematous plaques, some of which had a peripheral scale, on tbe dorsa of
CORRESPONDENCE
187
his hands, forearms, and feet. Scattered pustules were seen within the plaques. There was thick scale on the scalp. General examination was otherwise normal. Over the next few days the plaques coalesced and the erythema and pustulation became generalized. He was febrile, his temperature spiking up to i9°C. On admission the full blood count, biochemistry. C-reactive protein and urine microscopy were normal. Subsequently the white cell count rose to 29 x |{)''/l with a neutrophilia. serum albumin fell from 45 to 29 g/dl. the KSR increased to 44 mm/h and the C-reactive protein level to 109 mg/l { < H)). The ASO titre was
fest within the setting of haemophilia A. Further detailed studies are in progress. The improvement in affect and self-confidence seen in this teenager was striking. It is well documented that acne impairs self-confidence'' and employment opportunities." These features are also recognized in haemophiliacs. Adequate treatment of acne is therefore particularly desirable in these patients. We would, however, recommend caution when using isotretinoin in patients with haemophilia until further detailed studies of fibrinolysis in vivo are available. Departments of Dermatology atid *Haematologii. Queen Elizabeth Hospital Kitig's Lynn. Norfolk PE3() 4ET. UK
G.M.DOOTSON J.KEIDAN* J.A.R.ANDbKSON
References 1 David M, Hodak K, [,owe NH. Adverse effects of retinoids. Med Toxicol Adverse Drug l-xp 1988; 3: 2 7 i - 8 8 . 2 lohnson TM. Rapini RP. Isotretinoin-induced thrombocytopfnia. I Am Acad Dermatol 1987: 17: S 58-9, } Hesdorffcr CS, Wcltman MD. Raftopouios H el a!. Thrombocytopenia caused by isotretinoin. S Afr Med / 1986; 70: 705-6. 4 Hamilton IA, Stimtilation of the plasminogen activator activity of human synovial fibroblasts by retinoids. Arthritis Rheimt 1 982; 25: 4i2-4(), 5 Bounameaux H. Reber G. Bounanicaux Y. Acute effects of retinoids on fibrinolysis before and after venous occlusion in healthy humans. ThrombRes 1988; 50: I7S-9. 6 )owett S, Ryan T. Skin disease and handicap: an anaiysis of the impact of skin conditions, Sov Sci Med 1985; 20: 425-9. 7 Ctinliffe W|. Acne and unemployment. Br j Dermato} 1986; 11 5: 386.
Generalized pustular psoriasis associated with bacterial endocarditis ofthe anterior papillary muscle SIR. Generalized pustular psoriasis (GPP) is an uncommon condition first described by von Zumbusch in 1910.' Exogenous precipitating factors are well recognized and include drugs, in particular a reduction in the dose of systemic or potent topical steroids.^ pregnancy,' sunburn.^ and infections.'' We report a case of GPP and bacterial endocarditis, an association which, to our knowledge, has not been described previously. This patient is of particular interest as the endocarditis affected the papillary muscle, a recognized but unusual phenomenon. A 24-year-old Moroccan man presented with a l-week history of a rash affecting the dorsa of his hands and feet. He gave a 20-year history of psoriasis affecting his scalp, arms and groins. He had used about 50 g of betamethasone dipropionate U 05% (Diprosone®) cream per week on the affected areas for many years, and 4 days before admission this had been changed to betamethasone valerate 0-1% cream in a 1 in 4 dilution (Betnovate RU®) which he had used sparingly. There was no history of rheumatic fever. On examination he was apyrexial. Tbere were erythematous plaques, some of which had a peripheral scale, on tbe dorsa of
CORRESPONDENCE
187
his hands, forearms, and feet. Scattered pustules were seen within the plaques. There was thick scale on the scalp. General examination was otherwise normal. Over the next few days the plaques coalesced and the erythema and pustulation became generalized. He was febrile, his temperature spiking up to i9°C. On admission the full blood count, biochemistry. C-reactive protein and urine microscopy were normal. Subsequently the white cell count rose to 29 x |{)''/l with a neutrophilia. serum albumin fell from 45 to 29 g/dl. the KSR increased to 44 mm/h and the C-reactive protein level to 109 mg/l { < H)). The ASO titre was
