A 57-year-old man comes to the physician for evaluation of a rash on his elbows and knees. He initially had the rash 3 years ago, and it reoccurs every 3-4 months in the same regions. The patient has no pruritus or discharge during the episodes but notices an occasional silvery scale.
Vital signs are within normal limits. Skin examination of the left elbow is shown below. There is no drainage from the lesions or tenderness to palpation.

Which of the following is the best next step in management of this patient?

Question

A 57-year-old man comes to the physician for evaluation of a rash on his elbows and knees.  He initially had the rash 3 years ago, and it reoccurs every 3-4 months in the same regions.  The patient has no pruritus or discharge during the episodes but notices an occasional silvery scale.
Vital signs are within normal limits.  Skin examination of the left elbow is shown below.  There is no drainage from the lesions or tenderness to palpation.

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_978c_d6f7_853d_73da92447e9c_MD0002_00 This patient's presentation is consistent with plaque psoriasis, the most common form of psoriasis in adults. Patients develop symmetrical, erythematous plaques involving the scalp, knees, back, and extensor surfaces of the elbows, with a raised border and often a light or silvery scale. Less commonly affected areas include the external ear canal, intertriginous areas, and nail plates (pitting). Most patients are otherwise asymptomatic, but some may develop pruritus. Topical glucocorticoids are the mainstay of therapy for localized mild to moderate plaque psoriasis (<5% of body surface area). High-potency agents (eg, betamethasone, clobetasol) should be used initially to treat thick plaques on extensor surfaces; these are given as a twice-daily application for up to 4 weeks. Longer treatment is an option, but it should be closely monitored and lower-potency agents should be considered. Alternate therapy includes topical vitamin D analogs (eg, calcipotriene) or topical retinoids. Moderate to severe disease (5%-10% of body surface area or disabling lesions of face, palm, or sole) usually requires systemic therapy (methotrexate, biologic immunomodulators such as etanercept) or phototherapy (Choice A). (Choices C and E) Low-potency topical steroids are indicated for facial and intertriginous plaque psoriasis as high-potency topical steroids can cause corticosteroid-induced skin atrophy in these areas. Topical calcineurin inhibitors (eg, tacrolimus) are also an alternate treatment for facial and intertriginous involvement. (Choice D) Oral corticosteroids are usually avoided for treating plaque psoriasis due to increased adverse effects compared to other systemic treatments. In addition, withdrawal of systemic steroids may lead to an abrupt flare of psoriasis. Educational objective: Mild to moderate plaque psoriasis is treated with high-potency topical steroids and emollients. Moderate to severe disease (involvement of 5%-10% of body surface area or disabling lesions of face, palm, or sole) usually requires systemic therapy (methotrexate, biologic immunomodulator such as etanercept) or phototherapy. __________ References: Topical therapies for the treatment of plaque psoriasis: systematic review and network meta-analyses. (http://www.ncbi.nlm.nih.gov/pubmed/23413913) Topical therapies for the treatment of plaque psoriasis. (http://www.ncbi.nlm.nih.gov/pubmed/19916297)

A 57-Year-Old Man Comes to the Physician for Evaluation of a Rash