Recurrent angular cheilitis in a patient with mucocutaneous pemphigus vulgaris

A 61-year-old woman with pre-existing mucocutaneous pemphigus vulgaris (PV) diagnosed in 2006 (oral mucosal erosions and cutaneous blisters, with histological findings of acantholytic suprabasal cleft), developed painful cracks on both corners of her mouth in December 2012. Oral fluconazole 150 mg and mouth rinsing with nystatin led to moderate improvement, but further recurrences occurred. She was receiving treatment with prednisone 30 mg on alternate days and azathioprine 100 mg/day, and did not present any other cutaneous or mucosal erosions. The immunosuppressive drugs were tapered off gradually. In February 2013, the right commissural lesion suddenly became hypertrophic, and fissures appeared on the vermilion of the lips. A crusted erosion was also seen on the right nasal mucosa (Fig. 1). Blood count showed a high absolute eosinophil count (1587/mm; normal range 40-400/mm), with negative parasitology in three stool samples.