A 40-year-old man comes to the physician for evaluation of a rash involving his knees and shins. The rash has been present for 9 months with mild itching that worsens in winter. No other areas of the patient's body are involved, and he has no musculoskeletal symptoms. His general health is good and he takes no medications.
A general physical examination is within normal limits. Nail examination is normal. His knees are shown in the photograph below.

What would be the most appropriate initial therapy for this patient?

Question

A 40-year-old man comes to the physician for evaluation of a rash involving his knees and shins.  The rash has been present for 9 months with mild itching that worsens in winter.  No other areas of the patient's body are involved, and he has no musculoskeletal symptoms.  His general health is good and he takes no medications.
A general physical examination is within normal limits.  Nail examination is normal.  His knees are shown in the photograph below.

What would be the most appropriate initial therapy for this patient?

Quizplus · Accepted Answer

This patient has plaque psoriasis, the most common form of psoriasis. It is characterized by sharply demarcated, erythematous plaques with an overlying thick, silvery scale. These lesions are most often seen on extensor surfaces such as the elbows, knees, hands, feet, and trunk. Psoriasis is usually graded as mild (affecting < 3% of the body), moderate (affecting 3%-10% of the body), or severe (affecting > 10% of the body). Treatment modalities are chosen based on the severity of disease, sites of involvement, relevant comorbidities, patient preference, efficacy, and patient response. Those with mild-to-moderate plaque psoriasis (as in this patient) should be treated initially with topical corticosteroids and emollients. Alternate therapies include tar, topical retinoids (eg, tazarotene), and topical vitamin D (eg, calcipotriene, calcitriol). Although topical vitamin D analogues are effective as monotherapy, combination therapy with topical corticosteroids is more effective than either therapy alone. For facial or intertriginous involvement, topical tacrolimus (Choice E) or pimecrolimus may be used as a corticosteroid-sparing agent as chronic corticosteroid use in these areas can cause harmful skin effects such as atrophy, telangiectasia, and perioral dermatitis. In consultation with a dermatologist, patients with moderate-to-severe plaque psoriasis should be treated initially with phototherapy (Choice C). Patients with contraindications to phototherapy (eg, history of melanoma, extensive nonmelanoma skin cancer), who fail phototherapy, or who have moderate-to-severe disease and psoriatic arthritis should be treated with a systemic agent. Systemic therapy includes immunosuppressive or immunomodulatory drugs such as methotrexate, cyclosporine, and biologic agents (eg, etanercept) (Choices A and B). Educational objective: Patients with mild-to-moderate plaque psoriasis should be treated initially with topical corticosteroids and emollients. Combination therapy with topical corticosteroids and vitamin D is more effective than either therapy alone. For facial or intertriginous involvement, topical tacrolimus or pimecrolimus may be used as corticosteroid-sparing agents. Phototherapy and systemic therapies (eg, methotrexate, biologic agents) should be used for moderate-to-severe disease in consultation with a dermatologist. __________ References: Current and future management of psoriasis. (http://www.ncbi.nlm.nih.gov/pubmed/17658398) Topical treatments for chronic plaque psoriasis. (http://www.ncbi.nlm.nih.gov/pubmed/19370616)

A 40-Year-Old Man Comes to the Physician for Evaluation of a Rash