CORRECT DIAGNOSIS:
Eruptive Psoriasis
DISCUSSION:
Psoriasis is a common skin disease reported to affect up to 1 to 2% of the population worldwide. The prevalence may be as high as 4.6% in the U.S. While the skin is most commonly affected, the nails, mucous membranes, joints, and eyes can also be involved. Ocular involvement, while rare, can involve the lids, cornea, uvea, and lacrimal sac. Although the etiology is not well understood, the disease seems to be affected by genetic, hormonal, pharmacological, infectious, environmental, and psychological factors. Provoking factors such as streptococcal and HIV infections have been observed in up to 44% of patients. While multiple factors are involved, there is strong evidence that T lymphocyte activation plays a major role in the pathogenesis of the disease.
Clinical features are variable. The most common manifestation of psoriasis is chronic plaque psoriasis. Lesions are characterized by well defined erythematous, thickened scaly plaques predominately located on the extensor surfaces, scalp, hands, and feet. Less commonly, guttate psoriasis, erythrodermic psoriasis, generalized pustular psoriasis, psoriasis of the palms and soles, and acrodermatitis continua of Hallopeau are encountered. While treatment efforts aim to control these lesions, the course of the psoriatic disease is unpredictable.2 In immunocompromised patients, particularly in HIV populations, severe exacerbations and atypical presentations are common.3
Our patient presented with a unique clinical manifestation of nodular, hyperkeratotic psoriasis affecting his trunk, extremities, and face. This was believed to be an acute exacerbation of preexisting chronic plaque psoriasis. As his therapeutic trial of etanercept was both brief and suboptimal, a direct correlation is unlikely.4,5
Histopathologic findings were consistent with an eruptive process. Eruptive psoriasis is the term used for an acute exacerbation of chronic plaque psoriasis or used synonymously with acute, guttate psoriasis usually associated with streptococcal infections in the pediatric population. Rook et al. use the term rupiod, elephantine and ostraceous to describe various presentations of these grossly hyperkeratotic plaques.6 Eruptive psoriasis arising from preexisting chronic plaque psoriasis, while rare, has been seen with increasing frequency in the HIV population. While elucidation of precipitating factors in our patient is difficult, further investigation into immune status is warranted. Although previous HIV tests were negative, our patient deferred further HIV testing.
TREATMENT:
Our patient was initially prescribed fluocinonide (Lidex®) 0.05% ointment BID for his pruritus pending histopathologic evaluation. Following pathologic confirmation of eruptive psoriasis, the treatment regimen was changed from fluocinonide ointment to clobetasol propionate (Temovate®) 0.05% ointment BID and calcipotriene (Dovonex®) 0.005% ointment BID.
Other treatment options including oral retinoids, phototherapy, and biologic therapies were discussed at length with the patient. Due to economic and insurance restrictions, he was subsequently referred to a tertiary academic institution for possible enrollment in investigational treatment trials for psoriasis.
REFERENCES:
Bolognia, J. L., Jorizzo, J. L., & Rapini, R. P. (2003). Dermatology (1st ed., pp. 125-149). London: Mosby.
Odom, R. B., James, W. D., & Berger, T. G. (2000). Andrew’s Diseases of the Skin: Clinical Dermatology (9th ed., pp. 218-223). Philadelphia: W.B. Saunders Company.
Garman, M., & Tyring, S. (2002). The cutaneous manifestations of HIV infection. Dermatologic Clinics, 20(2), 193-208.
Papp, K. A. (2004). Etanercept in psoriasis. Expert Opinion on Pharmacotherapy, 5(10), 2139-2146.
Sobell, J. M., & Hallas, S. J. (2003). Systemic therapies for psoriasis: Understanding current and newly emerging therapies. Seminars in Cutanous Medicine and Surgery, 22(3), 187-195.
Rook, A., Wilkinson, D. S., & Ebling, F. J. G. (1998). Textbook of Dermatology (6th ed., p. 1599). Oxford: Blackwell.
