22 years old male Mr. X ,coming from Vellore, Student, unmarried, has come with c/o red, raised, scaly skin lesions all over the body for the past 4 years and exacerbation for last 2 months.

 HOPI: Pt was apparently normal 4 years back. Then he developed red scaly skin lesions started over extensor aspect of forearm then extends to lower legs for which he took treatment at Vellore medical college for 3 and half years.

For past 6 months, he didn’t take any treatment.

For the last 2 months ,he had exacerbation of lesions and c/o red, raised scaly skin lesions over extensor aspect of forearm, lower limbs, back and lower abdomen.

H/o moderate, continuous itching present.

H/o scaling present, non-odorous, moderate amount, loose scales, h/o winter exacerbation present

No h/o trauma or drug intake prior to the lesion

No h/o sore throat, fever, abdominal pain, vomiting, diarrhea prior to the lesion

No h/o sexual exposure prior to the lesion

No h/o oral ulcer and photosensitivity (SLE)

No h/o stressful event prior to the lesion

H/o suggestive of Koebners+

Complication history:

No h/o low backache, hip ,leg pain, swelling, morning stiffness, difficulty in movements

No h/o recurrent abdominal pain, swelling, bloating, irregular bowel movements

No h/o chest pain, palpitation, breathlessness, rapid gain in weight

No h/o spread of lesions to entire body

No h/o pus filled lesions and fever

Treatment history:

Pt was treated with T. Mtx 7.5 mg/week and topicals for 3 and half years, then discontinued for past 6 months.

Past history:

Similar illness in the past 4 years back

Not a k/c/o DM/HT/TB/ epilepsy/ asthma/ hyperthyroid

Personal history:

Mixed diet- zinc reduces psoriasis

Not a smoker/alcoholic

Not promiscus

Family history:

No similar illness in family members.

General examination

  • GC- good
  • Afebrile
  • Well built
  • No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal oedema

PR-80

BP-120/80

BMI- 28

Systemic examination:

  • CVS- S1 S2 +, no murmurs
  • RS- B/L AE+
  • CNS- NFND
  • PR- Not done

O/E:

  • Well defined, B/L symmetrical , erythematous, scaly plaques over extensor aspects of both forearms and anterior aspect of both legs, lower abdomen, back ,dorsum of hand over interphalangeal joint. Plaques of varying sizes present
  • Few popular lesions seen over back, elbow
  • Scaling +
  • Auspitz sign+
  • No evidence of erythroderma , pustules

PASI- 32.7 

  • Scalp normal
  • Nail normal- fingers and toes
  • Oral and  genital mucosa normal
  • Palms and soles normal
  • Joints normal

SUMMARY:

22 years old male, student came with raised, red scaly skin lesions all over the body for 4 years and exacerbation in last 2 months and discontinued treatment for last 6 months, auspitz sign+, PASI score of 32.7, without scalp/joint/nail/palms and soles involvement and without comorbidities

DIAGNOSIS: Chronic Plaque Psoriasis.

In view of bilateral symmetrical well demarcated
scaly erythematous (salmon coloured) plaques on the
extensors of extremities/ trunk/ lumbosacral with
silvery white scaling…… Auspitz positive.

  • Bimodal: 16-22 & 57-62 years.
  • Type I psoriasis : Early onset: < 40 years , family history + , Severe
  • Type II psoriasis: Late, >40 years.
  • Psoriatic arthritis: 4th decade
  • Guttate: children,young adults.
  • Palmoplantar, pustulosis: late age
  • Acrodermatitis continua : young adults
  • Inverse, erythrodermic: late onset.

Parakeratosis, Munros microbscesses, Hypogranulosis
Spongiform pustule of kogoj, Suprapapilary thinning
of epidermis, regular elongation of clubshaped /
camelfoot rete ridges, dilated and tortous capillaries
in papillary dermis

  • Reiters disease / Reactive arthiritis
  • Seborrheic dermatitis
  • Secondary Syphilis
  • Pityriasis Lichenoides Chronica
  • Parapsoriasis
  • Drug induced papulosquamous eruptions
  • Subacute Lupus erythematosus
  • Lichen Planus(guttate papulosquamous lesions)
  • Lupus vulgaris
  • But it will vary according to patient

There is no preceding history of diarrhea/ urethritis,
limpet like crusts, circinate balanitis,keratoderma
blenorrhagicum,annulus migrans, tendon friction
rubs and o cular complaints(uveitis) with
arthritis.(reactive)

There is no history of sexual exposure, chancre in thegenitals, absence of pruritus, deep dermal tenderness positivity,epitrochlear lymphadenopathy,mucous patches, condyloma lata, pigmentation or papulosquamous lesions in the palms and soles, with collarette of scaling (Biette’s collar).

Lesions are not reddish brown papules with wafer
like (oblaten) scales which on removal leaves behind
glistening shiny surface.Sometimes deep dermal
tenderness test may be positive.No scalp
involvement/ pitting nails.

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About Author

Dr. Howthul Alam

MD DVL Postgraduate Madras Medical College

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