More Than Skin Deep

1. About a year ago, this 40-year-old man developed scaling on the distal one-third of his thumbnail. The condition began to worsen, leaving most of his thumb covered by thick adherent white scales on a pinkish base with sharply defined margins. The adjacent thumbnail has focal areas of pitting in the nail plate, as well as yellowish discoloration on the distal edge.

Diagnosis: The most likely diagnosis is psoriasis, which can manifest with localized involvement.

For more information, see “Thumb: Scaling with Pitted Nail Plate.” Clin Rev. 2013 March;23(3):11.

For the next photograph, proceed to the next page >>

2. A 10-year-old girl has had patches of dry skin appearing and disappearing on her arms, legs, and neck for years. Recently manifested on her extensor forearm is an annular, distinctly salmon-pink plaque with a tenacious white scale. Scaly areas are observed in both postauricular sulci; several tiny pits are seen on her fingernails.

Diagnosis: It would be difficult to imagine a more clear-cut case of psoriasis, not only manifesting with a classic plaque on the extensor forearm but also with corroboratory stigmata behind the ears and classic fingernail pits.

It’s helpful to know that psoriasis affects almost 3% of the white population in the United States, meaning that you will see it with considerable frequency. It would also help if you knew the diagnosis can be corroborated by identification of other, lesser known features.

For more information, see “Girl, 10, Asks Tough Questions About Skin Problem.” Clin Rev. 2015;25(8):W2.

For the next photograph, proceed to the next page >>

3. A 62-year-old woman complained bitterly of itching on the soles of both feet. Both insteps are covered with discrete, confluent papules and tiny pustules on an erythematous and hyperpigmented (brown), sharply demarcated, and highly symmetrical base. No such lesions appear elsewhere.

Diagnosis: Palmoplantar pustulosis is the term most often used to describe a fairly common form of psoriasis typified by this case. Many patients are genetically predisposed to psoriasis, but they may require a trigger to set it off, such as strep infection or occasionally, medication. Notable among the latter are the b-blockers and lithium. Stress is often involved as well.

The bilateral symmetrical involvement of both insteps is highly suggestive of this diagnosis, which often also affects either peripheral or central palms. A secondary form of neurodermatitis (itch–scratch–itch cycle) can follow, complicating the picture and perpetuating the problem.

For more information, see “Pruritic Rash on Both Soles.” Clin Rev. 2012 Jan;22(1).

For the next photograph, proceed to the next page >>

4. The patient presented with fiery red, burned looking skin covering ≥90% of the skin surface and shedding in large "sheets" instead of smaller scales. He was monitored for fever, systemic symptoms, and multiorgan dysfunction.

Photo courtesy of Peter A. Lio, MD, and Alisa McQueen, MD

Diagnosis: This patient was given a diagnosis of erythrodermic psoriasis. This form of psoriasis can be life-threatening.

For more information, see “Derm emergencies— detecting early signs of trouble.” J Fam Pract. 2012 February;61(2):71-78. 

For the next photograph, proceed to the next page >>

5. This 18-year-old patient had multiple, erythematous papules and plaques with a fine scale over her face, neck, trunk, and lower legs. She noted that the eruption had developed after a sore throat 2 weeks earlier and that it was itchy.

Photos courtesy of David A. Boyd, MD

Diagnosis: Guttate psoriasis was diagnosed in this patient based on her history and physical exam, a throat culture that was positive for group A beta-hemolytic streptococci, and blood work that showed an elevated antistreptolysin O titer. Further confirmation was obtained via punch biopsy.

Guttate psoriasis is a fairly uncommon form of psoriasis, affecting approximately 2% of patients with psoriasis.¹ It is characterized by the abrupt onset of pruritic, salmon-pink 1- to 10-mm droplike lesions with fine scale that may spread to the face, but spare the palms and soles. It’s uncommon for this sub-type of psoriasis to involve the nails.

Guttate psoriasis affects individuals younger than 30; there appears to be no gender predilection.² The rash usually appears 2 to 3 weeks after an upper respiratory group A beta-hemolytic streptococci infection. Although less common, there have also been reports of guttate psoriasis associated with perianal streptococcal disease.²

1. Habif TP. Clinical Dermatology. 4th ed. St. Louis, Mo: Mosby; 2004;209-239
2. Honig PJ. Guttate psoriasis associated with perianal streptococcal disease. J Pediatr. 1988;113:1037-1039.

For more information, see “Teen with a diffuse erythematous, pruritic eruption.” J Fam Pract. 2011 January;60(1):37-39.

1. About a year ago, this 40-year-old man developed scaling on the distal one-third of his thumbnail. The condition began to worsen, leaving most of his thumb covered by thick adherent white scales on a pinkish base with sharply defined margins. The adjacent thumbnail has focal areas of pitting in the nail plate, as well as yellowish discoloration on the distal edge.

Diagnosis: The most likely diagnosis is psoriasis, which can manifest with localized involvement.

For more information, see “Thumb: Scaling with Pitted Nail Plate.” Clin Rev. 2013 March;23(3):11.

For the next photograph, proceed to the next page >>

2. A 10-year-old girl has had patches of dry skin appearing and disappearing on her arms, legs, and neck for years. Recently manifested on her extensor forearm is an annular, distinctly salmon-pink plaque with a tenacious white scale. Scaly areas are observed in both postauricular sulci; several tiny pits are seen on her fingernails.

Diagnosis: It would be difficult to imagine a more clear-cut case of psoriasis, not only manifesting with a classic plaque on the extensor forearm but also with corroboratory stigmata behind the ears and classic fingernail pits.

It’s helpful to know that psoriasis affects almost 3% of the white population in the United States, meaning that you will see it with considerable frequency. It would also help if you knew the diagnosis can be corroborated by identification of other, lesser known features.

For more information, see “Girl, 10, Asks Tough Questions About Skin Problem.” Clin Rev. 2015;25(8):W2.

For the next photograph, proceed to the next page >>

3. A 62-year-old woman complained bitterly of itching on the soles of both feet. Both insteps are covered with discrete, confluent papules and tiny pustules on an erythematous and hyperpigmented (brown), sharply demarcated, and highly symmetrical base. No such lesions appear elsewhere.

Diagnosis: Palmoplantar pustulosis is the term most often used to describe a fairly common form of psoriasis typified by this case. Many patients are genetically predisposed to psoriasis, but they may require a trigger to set it off, such as strep infection or occasionally, medication. Notable among the latter are the b-blockers and lithium. Stress is often involved as well.

The bilateral symmetrical involvement of both insteps is highly suggestive of this diagnosis, which often also affects either peripheral or central palms. A secondary form of neurodermatitis (itch–scratch–itch cycle) can follow, complicating the picture and perpetuating the problem.

For more information, see “Pruritic Rash on Both Soles.” Clin Rev. 2012 Jan;22(1).

For the next photograph, proceed to the next page >>

4. The patient presented with fiery red, burned looking skin covering ≥90% of the skin surface and shedding in large "sheets" instead of smaller scales. He was monitored for fever, systemic symptoms, and multiorgan dysfunction.

Photo courtesy of Peter A. Lio, MD, and Alisa McQueen, MD

Diagnosis: This patient was given a diagnosis of erythrodermic psoriasis. This form of psoriasis can be life-threatening.

For more information, see “Derm emergencies— detecting early signs of trouble.” J Fam Pract. 2012 February;61(2):71-78. 

For the next photograph, proceed to the next page >>

5. This 18-year-old patient had multiple, erythematous papules and plaques with a fine scale over her face, neck, trunk, and lower legs. She noted that the eruption had developed after a sore throat 2 weeks earlier and that it was itchy.

Photos courtesy of David A. Boyd, MD

Diagnosis: Guttate psoriasis was diagnosed in this patient based on her history and physical exam, a throat culture that was positive for group A beta-hemolytic streptococci, and blood work that showed an elevated antistreptolysin O titer. Further confirmation was obtained via punch biopsy.

Guttate psoriasis is a fairly uncommon form of psoriasis, affecting approximately 2% of patients with psoriasis.¹ It is characterized by the abrupt onset of pruritic, salmon-pink 1- to 10-mm droplike lesions with fine scale that may spread to the face, but spare the palms and soles. It’s uncommon for this sub-type of psoriasis to involve the nails.

Guttate psoriasis affects individuals younger than 30; there appears to be no gender predilection.² The rash usually appears 2 to 3 weeks after an upper respiratory group A beta-hemolytic streptococci infection. Although less common, there have also been reports of guttate psoriasis associated with perianal streptococcal disease.²

1. Habif TP. Clinical Dermatology. 4th ed. St. Louis, Mo: Mosby; 2004;209-239
2. Honig PJ. Guttate psoriasis associated with perianal streptococcal disease. J Pediatr. 1988;113:1037-1039.

For more information, see “Teen with a diffuse erythematous, pruritic eruption.” J Fam Pract. 2011 January;60(1):37-39.

1. About a year ago, this 40-year-old man developed scaling on the distal one-third of his thumbnail. The condition began to worsen, leaving most of his thumb covered by thick adherent white scales on a pinkish base with sharply defined margins. The adjacent thumbnail has focal areas of pitting in the nail plate, as well as yellowish discoloration on the distal edge.

Diagnosis: The most likely diagnosis is psoriasis, which can manifest with localized involvement.

For more information, see “Thumb: Scaling with Pitted Nail Plate.” Clin Rev. 2013 March;23(3):11.

For the next photograph, proceed to the next page >>

2. A 10-year-old girl has had patches of dry skin appearing and disappearing on her arms, legs, and neck for years. Recently manifested on her extensor forearm is an annular, distinctly salmon-pink plaque with a tenacious white scale. Scaly areas are observed in both postauricular sulci; several tiny pits are seen on her fingernails.

Diagnosis: It would be difficult to imagine a more clear-cut case of psoriasis, not only manifesting with a classic plaque on the extensor forearm but also with corroboratory stigmata behind the ears and classic fingernail pits.

It’s helpful to know that psoriasis affects almost 3% of the white population in the United States, meaning that you will see it with considerable frequency. It would also help if you knew the diagnosis can be corroborated by identification of other, lesser known features.

For more information, see “Girl, 10, Asks Tough Questions About Skin Problem.” Clin Rev. 2015;25(8):W2.

For the next photograph, proceed to the next page >>

3. A 62-year-old woman complained bitterly of itching on the soles of both feet. Both insteps are covered with discrete, confluent papules and tiny pustules on an erythematous and hyperpigmented (brown), sharply demarcated, and highly symmetrical base. No such lesions appear elsewhere.

Diagnosis: Palmoplantar pustulosis is the term most often used to describe a fairly common form of psoriasis typified by this case. Many patients are genetically predisposed to psoriasis, but they may require a trigger to set it off, such as strep infection or occasionally, medication. Notable among the latter are the b-blockers and lithium. Stress is often involved as well.

The bilateral symmetrical involvement of both insteps is highly suggestive of this diagnosis, which often also affects either peripheral or central palms. A secondary form of neurodermatitis (itch–scratch–itch cycle) can follow, complicating the picture and perpetuating the problem.

For more information, see “Pruritic Rash on Both Soles.” Clin Rev. 2012 Jan;22(1).

For the next photograph, proceed to the next page >>

4. The patient presented with fiery red, burned looking skin covering ≥90% of the skin surface and shedding in large "sheets" instead of smaller scales. He was monitored for fever, systemic symptoms, and multiorgan dysfunction.

Photo courtesy of Peter A. Lio, MD, and Alisa McQueen, MD

Diagnosis: This patient was given a diagnosis of erythrodermic psoriasis. This form of psoriasis can be life-threatening.

For more information, see “Derm emergencies— detecting early signs of trouble.” J Fam Pract. 2012 February;61(2):71-78. 

For the next photograph, proceed to the next page >>

5. This 18-year-old patient had multiple, erythematous papules and plaques with a fine scale over her face, neck, trunk, and lower legs. She noted that the eruption had developed after a sore throat 2 weeks earlier and that it was itchy.

Photos courtesy of David A. Boyd, MD

Diagnosis: Guttate psoriasis was diagnosed in this patient based on her history and physical exam, a throat culture that was positive for group A beta-hemolytic streptococci, and blood work that showed an elevated antistreptolysin O titer. Further confirmation was obtained via punch biopsy.

Guttate psoriasis is a fairly uncommon form of psoriasis, affecting approximately 2% of patients with psoriasis.¹ It is characterized by the abrupt onset of pruritic, salmon-pink 1- to 10-mm droplike lesions with fine scale that may spread to the face, but spare the palms and soles. It’s uncommon for this sub-type of psoriasis to involve the nails.

Guttate psoriasis affects individuals younger than 30; there appears to be no gender predilection.² The rash usually appears 2 to 3 weeks after an upper respiratory group A beta-hemolytic streptococci infection. Although less common, there have also been reports of guttate psoriasis associated with perianal streptococcal disease.²

1. Habif TP. Clinical Dermatology. 4th ed. St. Louis, Mo: Mosby; 2004;209-239
2. Honig PJ. Guttate psoriasis associated with perianal streptococcal disease. J Pediatr. 1988;113:1037-1039.

For more information, see “Teen with a diffuse erythematous, pruritic eruption.” J Fam Pract. 2011 January;60(1):37-39.