A 42-year-old man comes to the office due to skin lesions on his scalp and upper and lower limbs. He initially noticed scaly patches on his elbows, which rapidly progressed in size and number over the past 2 months. The lesions are not painful but are mildly pruritic. The patient has had stiffness and pain of the hand joints bilaterally for the last 2 weeks. He has never had similar lesions and has no medical problems besides genital herpes, which has not recurred for several years. The patient occasionally drinks alcohol but does not use tobacco or illicit drugs. Temperature is 37.1 C (98.7 F), blood pressure is 130/80 mm Hg, and pulse is 80/min. Skin examination shows several large, erythematous plaques covered by thick, adherent, silvery-white scales on the elbows, knees, sacrum, and scalp. When the scales are removed, pinpoint areas of hemorrhage can be observed. Which of the following diagnostic studies is most appropriate in management of this patient?

Question

A 42-year-old man comes to the office due to skin lesions on his scalp and upper and lower limbs.  He initially noticed scaly patches on his elbows, which rapidly progressed in size and number over the past 2 months.  The lesions are not painful but are mildly pruritic.  The patient has had stiffness and pain of the hand joints bilaterally for the last 2 weeks.  He has never had similar lesions and has no medical problems besides genital herpes, which has not recurred for several years.  The patient occasionally drinks alcohol but does not use tobacco or illicit drugs.  Temperature is 37.1 C (98.7 F), blood pressure is 130/80 mm Hg, and pulse is 80/min.  Skin examination shows several large, erythematous plaques covered by thick, adherent, silvery-white scales on the elbows, knees, sacrum, and scalp.  When the scales are removed, pinpoint areas of hemorrhage can be observed.  Which of the following diagnostic studies is most appropriate in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d387_9dfb_bc81_61ef13fe48d3_MD0003_00 This patient with scaly, erythematous plaques involving the extensor surfaces of the extremities, scalp, and sacrum has typical features of psoriasis. Psoriasis is characterized by keratinocyte proliferation, inflammation, and angiogenesis. Pinpoint bleeding following scraping of the scales (Auspitz sign) is a common finding. Extradermal manifestations include psoriatic arthritis (likely present in this patient), nail changes (eg, pitting), and inflammatory disorders of the eye (eg, conjunctivitis, uveitis). Factors that can trigger symptoms in psoriasis include local skin trauma (Koebner phenomenon), withdrawal from systemic glucocorticoids, and certain medications (eg, antimalarials, indomethacin, propranolol). In addition, certain infections, especially HIV and streptococcal pharyngitis (which can also trigger guttate psoriasis), are associated with flares of psoriasis. In light of this patient's aggressive onset of psoriasis and history of sexually transmitted infection (eg, genital herpes), he should be offered screening for HIV infection. guttate psoriasis (Choice A) Acute febrile neutrophilic dermatosis (Sweet syndrome) is characterized by an abrupt onset of painful edematous papules, plaques, or nodules on the head, neck, and upper extremities. It is associated with hematologic malignancies, in addition to upper respiratory and gastrointestinal infections and inflammatory bowel disease. Acute febrile neutrophilic dermatosis (Choice B) Sarcoidosis is associated with a number of skin manifestations, which may precede the onset of pulmonary symptoms. Common findings include erythema nodosum (tender anterior tibial nodules) and lupus pernio (violaceous facial papules or nodules). erythema nodosum lupus pernio (Choice C) Paraneoplastic skin syndromes associated with gastric adenocarcinoma include acanthosis nigricans (velvety thickening of the skin in the neck or axillae) and explosive onset of numerous seborrheic keratoses (Leser-Trélat sign). Seborrheic keratoses are also associated with adenocarcinoma in other sites (eg, colon, pancreas). acanthosis nigricans Leser-Trélat sign (Choice D) Dermal signs of hepatitis C include porphyria cutanea tarda (blisters and scars, generally on sun-exposed areas), lichen planus (4Ps: purple, pruritic, polygonal papules/plaques), and cryoglobulinemic vasculitis (erythematous lower extremity papules or macules). porphyria cutanea tarda lichen planus cryoglobulinemic vasculitis (Choice F) Vitiligo is characterized by regional autoimmune destruction of melanocytes, leading to hypopigmentation. It is often associated with other autoimmune disorders, especially chronic lymphocytic (Hashimoto) thyroiditis and Graves disease. Vitiligo Educational objective: Factors that can lead to worsening of psoriasis include local skin trauma (Koebner phenomenon), withdrawal from systemic glucocorticoids, and certain medications (eg, antimalarials, indomethacin, propranolol). In addition, certain infections, especially HIV and streptococcal pharyngitis (which can also trigger guttate psoriasis), are associated with psoriasis. References: Particular clinical presentations of psoriasis in HIV patients. (http://www.ncbi.nlm.nih.gov/pubmed/22096050)

A 42-Year-Old Man Comes to the Office Due to Skin