A 32-year-old woman comes to the physician for the evaluation of a rash over her knees and elbows. She first noticed the rash 4 weeks ago. She has no associated symptoms of itching or joint pain. The patient has no significant past medical history. She takes oral contraceptive pills regularly. On physical examination, symmetric erythematous plaques are observed over the extensor surface of the knees and elbows. The plaques are covered with thick silvery scales as shown in the image below. Which of the following is the most appropriate initial treatment?

Question

A 32-year-old woman comes to the physician for the evaluation of a rash over her knees and elbows.  She first noticed the rash 4 weeks ago.  She has no associated symptoms of itching or joint pain.  The patient has no significant past medical history.  She takes oral contraceptive pills regularly.  On physical examination, symmetric erythematous plaques are observed over the extensor surface of the knees and elbows.  The plaques are covered with thick silvery scales as shown in the image below.  Which of the following is the most appropriate initial treatment?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be80_9179_8f63_d9824b4c11a1_MD0005_00 Psoriasis is a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick silvery scales. These lesions are typically seen over the scalp, knees, elbows, back, and nail plates. Patients are usually asymptomatic, but some may have mild itching. Most patients tend to have the disease for life and the severity varies significantly throughout the course of the disease. A variety of different treatment options (local and systemic) are available for the treatment of psoriasis. Topical corticosteroids are the mainstay of therapy for localized mild-to-moderate plaque psoriasis. High-potency agents (eg, fluocinonide, augmented betamethasone dipropionate 0.05%) 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 should be closely monitored, and lower-potency agents should be considered. The lesions may be covered with an occlusive barrier (eg, plastic wrap or occlusion tape) after application to maximize treatment effects. (Choice A) Methotrexate is very effective for severe psoriasis, psoriatic arthritis, and psoriasis involving the nails. It is typically used in a weekly low-dose regimen. (Choice B) Phototherapy with ultraviolet-B (UVB) radiation is generally recommended only for patients with extensive disease (eg, >10% of body surface area). Severe lesions may be treated with a combination of coal tar application and exposure to UVB light (Goeckerman regimen). (Choice C) Systemic corticosteroids should not be used due to the potential for inducing pustular psoriasis. (Choice E) Low-potency steroids (eg, hydrocortisone 1%) may be used on the face and intertriginous areas but are not as effective on extensor areas with thick psoriatic plaques. Educational objective: High-potency topical corticosteroids are the first-line therapy for mild-to-moderate, localized plaque psoriasis. References: Psoriasis. (http://www.ncbi.nlm.nih.gov/pubmed/23668525)

A 32-Year-Old Woman Comes to the Physician for the Evaluation