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Giant oral aphthous ulcers induced by nicorandil

tests, liver function tests and ultrasound of the abdomen were normal or negative. Quantitative analysis of porphyrins in urine (separated into fractions of uroporphyrins, coproporphyrins and carboxylic porphyrins) was performed by standard methods. Porphyrin levels were normal. Phototests and photopatch tests performed as described by Fujimoto et al. were negative. The histopathological features of a blister on the back of the hand were characterized as a subepidermal blister with denuded dermal papillae protruding into the blister cavity. Only occasional lymphocytes were seen in the dermis. Direct immunofluorescence was repeatedly negative. A diagnosis of pseudoporphyria associated with antiandrogen therapy was considered. Flutamide was replaced with bicalutamide, a new androgen-receptor antagonist, 50 mg/ day, in addition to goserelin, leading to permanent healing of the lesions. Pseudoporphyria is a condition characterized by clinical changes resembling PCT, in the absence of any demonstrable abnormality in porphyrin metabolism. It may be associated with several drugs, whose withdrawal is often curative. Differential diagnosis includes epidermolysis bullosa acquisita, in which direct immunofluorescence is positive for IgG deposits at the dermal– epidermal junction in perilesional skin. In contrast, direct immunofluorescence is not specific in pseudoporphyria, with occasional positivity around the blood vessels, as in PCT. Flutamide is a non-steroidal derivative of toluidine which blocks the action of both testosterone and dihydrotestosterone bycompeting with androgen receptors. The antiandrogenactivity of flutamide probably depends on conversion to 2-hydroxyflutamide in the liver. Cutaneous side-effects have rarely been described, with the exception of two reports of photosensitive dermatitis. In our patient, phototests and photopatch tests were negative. Replacement of flutamide with bicalutamide led to permanent healing. The mechanism of flutamide in inducing blisters is unknown, but it is well-known that cutaneous lesions of pseudoporphyria appear to be precipitated or aggravated by exposure to sunlight. A relevant factor in this case, as in the case with naproxen described by Burns, is that blisters developed only in areas of vitiligo on the dorsa of the hands, while normal skin was not affected. The absorption spectrum of flutamide has been reported to be 292 nm. The presence of melanin in normal skin may thus be sufficient to prevent flutamide-induced pseudoporphyria.