Enalapril is a widely used antihypertensive drug with a very powerful in vitro acantholytic effect. It has been known to potentially induce pemphigus in genetically predisposed subjects. The action mechanism is complex and still only partially understood. We describe the case of a 66-year-old man, affected with intermediary basal cell carcinoma, in whom the histological examination showed suprabasal acantholytic clefts in the perilesional epidermis. Surprisingly a second biopsy taken from the apparently healthy skin of his back confirmed the presence of acantholytic changes. Clinical signs of pemphigus were absent. The patient’s history did not reveal any relevant data but a mild arterial hypertension that had been treated for 1 year with 10 mg enalapril. Taking into account the patient’s history (enalapril long-term administration), the absence of any bullous or erosive lesions and the histological findings, a diagnosis was made of in vivo enalapril-induced acantholysis.

de Angelis E, Lombardi ML, Grassi M, Ruocco V: Enalapril: A powerful in vitro non-thiol acantholytic agent. Int J Dermatol 1992;31: 722–724.
Shelton RM: Pemphigus foliaceus associated with enalapril. J Am Acad Dermatol 1991;24: 503–504.
Bottoni U, Innocenzi D, Camplone G, Frascione A, Annetta A, Carlesimo OA: Pemfigo polimorfo farmaco-indotto. Dermatol Clin 1992;12:162–168.
Ruocco V, Satriano RA, Guerrera V: ‘Two step’ pemphigus induction by ACE-inhibitors. Int J Dermatol 1992;31:33–36.
Ruocco V, de Angelis E, Lombardi ML: Drug-induced pemphigus. II. Pathomechanisms and experimental investigations. Clin Dermatol 1993;11:507–513.
Esposito C, Ruocco V, Cozzolino A, Lo Schiavo A, Lombardi ML, Porta R: Are acantholysis and transglutaminase inhibition related phenomena? Dermatology 1996;193:221–225.
Ruocco V, Brenner S, Ruocco E, de Angelis F, Lombardi ML: Different patterns of in vitro acantholysis in normal human skin samples explanted from different sites of the body. Int J Dermatol 1998;37:18–22.
Lever WF, Schaumburg-Lever G: Tumors and cysts of the epidermis; in Lever WF, Schaumburg-Lever G (eds): Histopathology of the Skin, ed 6. Philadelphia, Lippincott, 1983, pp 488–513.
Wolf R, Bernstein-Lipschitz L, Rotem A: Paget’s disease of the nipple resembling an acantholytic disease on microscopic examination. Dermatologica 1989;179:42–44.
Grover RW: Transient acantholytic dermatosis. Arch Dermatol 1970;101:426–434.
Simon RS, Bloom D, Ackerman AB: Persistent acantholytic dermatosis. Arch Dermatol 1976; 112:1429–1431.
Fawcett HA, Miller JA: Persistent acantholytic dermatosis related to actinic damage. Br J Dermatol 1983;109:349–354.
Ruocco V, Pinto F, D’Avino M, Baroni A, Ruocco E: L’acantolisi biochimica in vitro. Ann It Dermatol Clin Sper 1996;50:155–164.
Wucherpfenning KW, Yu B, Bhol K, Monos DS, Argyris E, Karr RW: Structural basis for major histocompatibility complex (MHC)-linked susceptibility to autoimmunity: Charged residues of a single MCH binding pocket confer selective presentation of a self-peptide in pemphigus vulgaris. Proc Natl Acad Sci USA 1995; 92:11935–11939.
Brandsen R, Frusic-Zlotkin M, Lyubimov H, Yunes F, Michel B, Tamir A, Milner Y, Brenner S: Circulating pemphigus IgG in families of patients with pemphigus: Comparison of indirect immunofluorescence, direct immunofluorescence and immunoblotting. J Am Acad Dermatol 1997;36:44–52.
Lombardi ML, Mercuro O, Tecame G, Fusco V, Ruocco V, Salerno A: Molecular analysis of HLA DRB1 and DQB1 on Italian patients with pemphigus vulgaris. Tissue Antigens 1996;47: 228–230.
Brenner S, Ruocco V, Wolf R, de Angelis E, Lombardi ML: Pemphigus and dietary factors. In vitro acantholysis by allyl compounds of the genus Allium. Dermatology 1995;190:197–202.
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