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Case Presentation A 69-year-old Malay lady was referred to the dermatology clinic with complaint of painful nail-beds of fingers and toes for the past 10-weeks. She was recently diagnosed with non-small cell lung carcinoma stage 1V and was started on oral Afatinib 40 mg, then tapered to 30 mg daily after 2 weeks due to severe oral ulcers which then improved. Four weeks post-treatment she started noticing acute nail symptoms, her fingers and toes being were swollen, red and tender. She also had intermittent diarrhoea. There were no other associated symptoms of fever, rash, arthritis and numbness. No history of trauma or history of pedicure and manicure. Further history she also revealed that she had blackish discoloration of the left big toenail for 3-years. She is a non-smoker, no significant family history and no past medical history. She had history of hysterectomy in 1997 due to fibroids and is now a retired economist living with her husband and has no children. Prior to referral to dermatologist she was treated with a week of oral Erythromycin 400 mg bd for suspected bacterial induced paronychia, with topical fucidin and clotrimazole bid, by her oncologist, but condition did not improve. Blood results showed full blood count Hb-12.4 g/dl, WBC-5.8x109 /l, Platelet-369x109 /L. Renal profile and Liver function test were normal. ESR was 21 mm/hr. Calcium, phosphate and fasting blood glucose also in normal range. Based on the pictures below, what is the most likely diagnosis? Figure 1 (a) Bilateral middle and index fingers showed grade 1-2 paronychia (nail-fold erythema and oedema). Right thumb had grade 2 paronychia (centre picture) with bogginess or 'pyogenic-granuloma like' eruption

Oral retinoids are among the drugs of choice for pustular psoriasis. Therapy with retinoids, including acitretin, is potent teratogens with other common side effects such as mucocutaneous involvement. Mucocutaneous side effects including dry lips (cheilitis), skin peeling, hair loss (alopecia), dry skin, or rhinitis are dose-related, with cheilitis occurring in more than 75% of patients receiving the highest doses of acitretin (75 mg/day). We report on a 37-year-old woman who developed folliculitis with acitretin which is a rare cutaneous side effect. She presented with eruptions pruritic papules with follicular pattern on anterior thigh and forearms after almost 1 year of treatment with acitretin (50mg OD) for pustular psoriasis. The skin lesion was treated successfully with skin dressing and antibiotic treatment and skin biopsy is suggestive of folliculitis. Several treatments for pustular psoriasis including topical steroids, methotrexate and oral prednisolone were ineffective or not tolerated. Treatment with acitretin which are 50mg OD provided partial resolution of skin lesions. The case is hereby reported because of its rarity and folliculitis must be considered in the differential diagnosis of a popular eruption, especially in patients with high dose acitretin.

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