A 45-year-old woman comes to the office due to a 6-month history of mild aching and stiffness in the joints of her hands. The symptoms are worse in the morning for about an hour and then gradually improve throughout the day. The patient has no previous medical problems and takes no medications. She does not use tobacco or illicit drugs, and drinks a glass of wine every day. Vital signs are normal. Physical examination shows multiple small, sharply demarcated and erythematous scaly plaques on the extensor surfaces of both elbows. The right hand is shown in the image below, and the left hand has similar abnormalities. X-rays of the hands reveal bony erosions with evidence of new bone formation at multiple distal interphalangeal joints. Which of the following is the most appropriate next step in management of this patient?

Question

A 45-year-old woman comes to the office due to a 6-month history of mild aching and stiffness in the joints of her hands.  The symptoms are worse in the morning for about an hour and then gradually improve throughout the day.  The patient has no previous medical problems and takes no medications.  She does not use tobacco or illicit drugs, and drinks a glass of wine every day.  Vital signs are normal.  Physical examination shows multiple small, sharply demarcated and erythematous scaly plaques on the extensor surfaces of both elbows.  The right hand is shown in the image below, and the left hand has similar abnormalities.  X-rays of the hands reveal bony erosions with evidence of new bone formation at multiple distal interphalangeal joints.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be81_2dbb_8f63_5fb4cd6745fa_MD0005_00 Psoriasis is a common inflammatory skin disorder characterized by sharply demarcated, erythematous plaques with a thick, silvery scale involving the scalp, knees, and extensor surface of the elbows, neck, and back. Involvement of the nails typically presents as pitting over the nail plates; severe nail involvement may eventually lead to destruction and separation of the nail plate from the nail bed (onycholysis). The diagnosis of psoriasis is generally made on clinical findings. Psoriatic arthritis is seen in approximately one third of patients with psoriasis and may precede the skin lesions. It is an inflammatory arthritis leading to pain and stiffness in the affected joints. Morning stiffness occurs in the majority of patients and is relieved by physical activity. Common sites of joint involvement include the distal interphalangeal joints and axial skeleton (ie, spondyloarthropathy with sacroiliitis or spondylitis). Patients with limited plaque psoriasis (<10% skin involvement) without associated arthritis are managed initially with topical glucocorticoids or vitamin D derivatives (eg, calcipotriene). However, those with more extensive disease or joint involvement require systemic treatment (eg, methotrexate). systemic treatment (Choice A) Topical glucocorticoids are frequently used in plaque psoriasis, but oral glucocorticoids are relatively contraindicated as they may trigger pustular psoriasis. (Choice B) Rheumatoid arthritis typically involves the metacarpophalangeal and proximal interphalangeal joints; distal interphalangeal involvement is unlikely. A negative rheumatoid factor assay is sometimes included in diagnostic criteria for psoriatic arthritis, but this test can be positive in up to 10% of patients with psoriatic arthritis, and anti-citrullinated peptide antibodies are also occasionally positive. (Choice D) Atypical forms of psoriasis may be difficult to diagnose on clinical grounds alone, necessitating a skin biopsy. However, microscopic examination of the scales is not diagnostic and not indicated. (Choice E) Narrowband ultraviolet B light therapy is typically used for widespread plaque psoriasis (eg, >10% of body surface area). Although it may produce a rapid response, it would be inadequate for management of psoriatic arthritis. In contrast, systemic therapy (eg, methotrexate, "biologics") would treat both the skin disease and the arthritis. Educational objective: Psoriasis is an inflammatory skin disorder characterized by well-demarcated, erythematous, scaly plaques. The diagnosis is generally made on the basis of characteristic skin lesions. Potential complications include nail and joint involvement. Psoriatic arthritis requires systemic therapy (eg, methotrexate). References: Management of psoriatic arthritis: the therapeutic interface between rheumatology and dermatology. (http://www.ncbi.nlm.nih.gov/pubmed/16973108) Treatment recommendations for psoriatic arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/18952643)

A 45-Year-Old Woman Comes to the Office Due to a 6-Month