A 52-year-old man comes to the office due to a skin rash behind his ears, which his wife first noticed 2 months ago. The rash is not painful but is mildly pruritic, and the patient frequently scratches the skin. He has tried using emollient creams and changing his soap and shampoo, but the rash is persistent and gradually enlarging. The patient has no history of skin disorders; current medical conditions include hypertension and hyperlipidemia. He has smoked a pack of cigarettes daily for the last 30 years and drinks 4-6 alcoholic beverages a week. The patient has worked in an automotive assembly plant for the last 10 years and previously worked in a coal mine.
Vital signs are normal. Skin examination findings are shown in the Exhibit. There is a similar scaly, erythematous lesion at the gluteal cleft.
Which of the following is the most likely diagnosis?

Question

A 52-year-old man comes to the office due to a skin rash behind his ears, which his wife first noticed 2 months ago.  The rash is not painful but is mildly pruritic, and the patient frequently scratches the skin.  He has tried using emollient creams and changing his soap and shampoo, but the rash is persistent and gradually enlarging.  The patient has no history of skin disorders; current medical conditions include hypertension and hyperlipidemia.  He has smoked a pack of cigarettes daily for the last 30 years and drinks 4-6 alcoholic beverages a week.  The patient has worked in an automotive assembly plant for the last 10 years and previously worked in a coal mine.
Vital signs are normal.  Skin examination findings are shown in the Exhibit.  There is a similar scaly, erythematous lesion at the gluteal cleft.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9796_25dd_853d_4ba288b0b992_MD0002_00 Psoriasis is a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick, silvery scales. The lesions are typically seen over the scalp, knees, elbows, back, gluteal cleft, and nail plates, and may be associated with mild itching. Complications include nail changes (eg, pitting, onycholysis), ocular inflammation (eg, conjunctivitis, uveitis), and psoriatic arthritis. Factors that can trigger symptoms include local skin trauma (Koebner phenomenon), infections, withdrawal from systemic glucocorticoids, and certain medications (eg, antimalarials, indomethacin, propranolol). Topical corticosteroids are the mainstay of therapy for mild-to-moderate plaque psoriasis. High-potency agents (eg, fluocinonide, augmented betamethasone dipropionate) should be used initially to treat thick plaques; these are given as a twice-daily application for up to 4 weeks. Longer treatment is an option but should be closely monitored, and patients should be transitioned to lower-potency agents if possible. (Choice A) Chronic contact dermatitis is caused by low-level exposure to allergens (eg, nickel, rubber, leather dyes) and presents with itching, scaling, and lichenification. It commonly develops at points of contact with jewelry (eg, neck, ear lobes) or clothing fasteners but would be unusual at the gluteal cleft. points of contact with jewelry (Choice B) Tinea capitis is characterized by scaly, erythematous patches of hair loss, often with pruritus, tender lymphadenopathy, and scarring. (Choice C) Lichen simplex chronicus (neurodermatitis) is characterized by thickened excoriated plaques caused by persistent scratching and rubbing. It is associated with anxiety disorders and typically occurs in areas that are easy to reach (eg, arms, legs, neck). Lichen simplex chronicus (neurodermatitis) (Choice E) Seborrheic dermatitis is characterized by an erythematous rash with an oily scale that typically affects the ears, skin folds of the central face, eyebrows, and scalp. It may resemble psoriasis but usually has finer scaling and does not show the prominent plaque formation seen in this patient. Seborrheic dermatitis Educational objective: Psoriasis is characterized by erythematous, well-defined plaques covered by thick, silvery scales. The lesions are typically seen over the scalp, knees, elbows, back, gluteal cleft, and nail plates, and may be associated with mild itching. Topical corticosteroids are the mainstay of therapy for localized mild-to-moderate plaque psoriasis. __________ References: Psoriasis. (http://www.ncbi.nlm.nih.gov/pubmed/23668525)

A 52-Year-Old Man Comes to the Office Due to a Skin