Sodium Valproate–Associated Psoriasis: A Case Report and Brief Literature Review

Psoriasis is a prevalent skin condition that requires long term therapy due to its high prevalence and the significant negative effects it can have on quality of life. Drugs may exacerbate preexisting psoriasis, induce psoriatic lesions on clinically unaffected skin in psoriasis patients, or precipitate the illness in people with a genetic predisposition or no family history of the condition. According to reports, some medications (eg, lithium, tetracycline) might either cause or worsen psoriasis.¹

Valproate is a broad-spectrum antiepileptic drug, effective against all seizure types.² The data on valproate causing induction or aggravation of psoriasis are sparse, and only a few cases have reported this association to date.^1–6 We present a rare case report of exacerbation of psoriasiform eruptions in a patient who was prescribed sodium valproate for seizures as well as an associated brief literature review of cases reporting this association. PubMed was searched on August 12, 2023, with the search terms valproate and psoriasis, and we reviewed 4 articles that were retrieved as well as 1 additional article on snowballing effect. For qualitative synthesis, we included 5 case reports.

Case Report

The patient was a 53-year-old, married Hindu man educated up up to the 12th class, belonging to middle-class socioeconomic status, who presented to the outpatient department with fluctuating complaints of absconding tendency, suspiciousness, decreased social interaction, odd behavior, muttering to self, and disturbed sleep for the past 20 years for which he was on irregular medications, but no medical records were available. For the last 6 years, the patient reported complex partial seizures lasting for 1 to 2 minutes and postictal confusion, vomiting, and no verbal responsiveness for 15–30 minutes. These episodes would occur erratically, sometimes once a month or once every 6 months.

The patient had a known case of psoriasis for the last 5 years but no family history of psoriasis. He was started on valproate for epilepsy (500 mg/d) 2 years ago and was on irregular follow-up. For the last few weeks, he had developed multiple sharply demarcated erythematous indurated scaly plaques of variable size (largest being 5 × 4 cm) on the bilateral limbs and dorsum of hands and scalp. The scales were silvery white in color, opaque, semiadherent, and not easily detachable. Scraping with a slide (grattage test) was positive. A few plaques did show crusting. Crusts were brown in color, nonfoul smelling, and semiadherent. A total of more than 70% of his body surface area was involved (Figure 1A). Citing nonresponse to methotrexate therapy, sodium valproate was suspected as an exacerbating agent. The daily dose was reduced to 250 mg, and after 5 days, his lesions cleared up substantially (Figure 1B). The patient was started on lacosamide 200 mg in a divided dose to control the seizures. He was continued on paliperidone (6 mg per day) for comorbid psychotic symptoms. The Naranjo Adverse Drug Reaction Probability Scale revealed a score of +5, which indicates probable association.⁷

Discussion

Psoriasis is a chronic skin disorder with a profound impact on patients’ quality of life. Certain drugs may induce, trigger, or exacerbate psoriasis. Early recognition and treatment of drug-induced/ exacerbated psoriasis result in better management of the primary disorder (per se) and psoriasis itself.

Sodium valproate is scarcely implicated in inducing or exacerbating psoriatic rash, with a total of 5 case reports (Table 1).^2–6 In contrast to our case, patients in 3 cases reportedly had no history of psoriasis.^3–5 All patients received valproate (dose range from 400 to 1 g per day) for epilepsy, except for 1 case⁶ in which the patient had bipolar disorder. The valproate induced occurrence of rash varied from almost immediately to a lag time of 1 year. Lastly, the rash was reported to be resolved within 9 days to 4 months of drug discontinuation (majority of cases) and dose reduction (in 1 case).⁶ Most cases reported widespread rash akin to our case report.^2–5

Sodium valproate’s chemical structure, specifically its carboxylic end, bears resemblance to nonsteroidal anti-inflammatory medications and captopril, which are known to trigger psoriasiform skin reactions.⁴ Valproic acid may exacerbate psoriasis by acting as a superantigen through the major histocompatibility complex.⁴ Since sodium valproate has a half-life of around 15 hours, this may explain why our patient’s skin lesions significantly improved within a week after the medicine was stopped.⁴ In conclusion, caution must be exercised when prescribing valproate to patients with preexisting psoriasis, as well as with other drugs known to induce psoriasis.

Article Information

Published Online: January 9, 2025. https://doi.org/10.4088/PCC.24cr03803
© 2025 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2025;27(1):24cr03803
Submitted: July 2, 2024; accepted October 15, 2024.
To Cite: Aggarwal A, Kumari N, Pattojoshi A, et al. Sodium valproate–associated psoriasis: a case report and brief literature review. Prim Care Companion CNS Disord. 2025; 27(1):24cr03803.
Author Affiliations: Department of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, Uttarakhand, India (Aggarwal, Garg, Chowdhry); Department of Dermatology, Venerology and Leprosy, Shri Guru Ram Rai Institute of Medical and Health Sciences, Uttarakhand, India (Kumari); Department of Psychiatry, Hi Tech Medical College, Bhubaneswar, India (Pattojoshi).
Corresponding Author: Simran Chowdhry, MD, Shri Guru Ram Rai Institute of Medical and Health Sciences, Patel Nagar, Dehradun, Uttarakhand 248001, India ([email protected]).
Relevant Financial Relationships: None.
Funding/Support: None.
Patient Consent: Informed consent was obtained from the patient to publish the case report, including the photographs. Information has been de-identified to protect anonymity.