CLINICAL HISTORY:

Signs and symptoms:  Intense pruritus and pain at lesion sites
Denies burning, discharge, fever or other constitutional
symptoms

Previous Treatment:  topical corticosteroids, blinded biologic trial drug for psoriasis (name unknown), phototherapy, and etanercept (Enbrel®)

Other information:  This patient was diagnosed with chronic plaque psoriasis in 1989. He had been treated with multiple different regimens without significant improvement. Three months prior to his presenting complaint, he was treated with etanercept 25 mg SQ injections BIW. He discontinued etanercept after two months of treatment secondary to complaint of severe headache. The patient presented to our clinic five months after discontinuation of the injectable biologic. He denies other psoriasis treatments between the time of discontinuation and the outbreak of his eruption. He denies household contacts with similar complaints, recent travel, or prior episodes of similar lesions.

PHYSICAL EXAM:

Multiple, large (ranging from 1-25 cm), discrete, well-defined, hyperkeratotic, hyperpigmented nodules and plaques on the scalp, face, trunk, and extremities.

There was no pre- or post-auricular, cervical, supraclavicular, or axillary lymphadenopathy noted.

LABORATORY TESTS:

Basic Metabolic Panel: Within Normal Limits

CBC with differential: Within Normal Limits

ANA: negative ESR: 4 (mm/Hr) RPR: non-reactive

Hepatitis Panel: Anti-HCV: non-reactive Anti-HBcore: non-reactive
Anti-HBsAg: non-reactive HBsAb qual: non-reactive
HAV Ab total: Positive HAV Ab(IgM): Negative

Cellular Immune Panel: CD3%: 71 Abs CD3+: 1427
CD4%: 42 Abs CD4+: 844
CD8%: 30 Helper/Suppressor Ratio: 1.4

DERMATOHISTOPATHOLOGY:

Histopathologic findings include eruptive hyperplasia with marked epidermal pallor, parakeratosis, numerous intraepidermal neutrophils, and thinning of the suprapapillary epidermal plate. The dermis shows evidence of edema, upward enlargement of the dermal papilla and dilitated, tortuous dermal capillaries.

DIFFERENTIAL DIAGNOSIS:

1.   Tumor stage CTCL
2.   Eruptive Keratoacanthoma
3.   Eruptive Psoriasis
4.   Deep fungal infection
5.   Sarcoidosis

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Eruptive Psoriasis

DISCUSSION:

Psoriasis is a common skin disease reported to affect up to 1 to 2% of the population worldwide. The prevalence may be as high as 4.6% in the U.S. While the skin is most commonly affected, the nails, mucous membranes, joints and eyes can also be involved. Ocular involvement, while rare, can involve the lids, cornea, uvea, and lacrimal sac. Although the etiology is not well understood, the disease seems to be affected by genetic, hormonal, pharmacological, infectious, environmental, and psychological factors. Provoking factors such as streptococcal and HIV infections have been observed in up to 44% of patients. While multiple factors are involved, there is strong evidence that T lymphocyte activation plays a major role in the pathogenesis of the disease.

Clinical features are variable. The most common manifestation of psoriasis is chronic plaque psoriasis. Lesions are characterized by well defined erythematous, thickened scaly plaques predominately located on the extensor surfaces, scalp, hands and feet. Less commonly, guttate psoriasis, erythrodermic psoriasis, generalized pustular psoriasis, psoriasis of the palms and soles, and acrodermatitis continua of Hallopeau are encountered. While treatment efforts aim to control these lesions, the course of psoriatic disease is unpredictable.2 In immunocompromised patients, particularly in HIV populations, severe exacerbations and atypical presentations are common.3

Our patient presented with a unique clinical manifestation of nodular, hyperkeratotic psoriasis affecting his trunk, extremities and face. This was believed to be an acute exacerbation of preexisting chronic plaque psoriasis. As his therapeutic trial of etanercept was both brief and suboptimal, direct correlation is unlikely.4,5

Histopathologic findings were consistent with an eruptive process. Eruptive psoriasis is the term used for an acute exacerbation of chronic plaque psoriasis, or used synonymously with acute, guttate psoriasis usually associated with streptococcal infections in the pediatric population. Rook et al. use the term rupiod, elephantine and ostraceous to describe various presentations of these grossly hyperkeratotic plaques.6 Eruptive psoriasis arising from preexisting chronic plaque psoriasis, while rare, has been seen with increasing frequency in the HIV population. While elucidation of precipitating factors in our patient is difficult, further investigation into immune status is warranted. Although previous HIV tests were negative, our patient deferred further HIV testing.

TREATMENT:

Actual treatment for this patient:

Our patient was initially prescribed fluocinonide (Lidex®) 0.05% ointment BID for his pruritus pending histopathologic evaluation. Following pathologic confirmation of eruptive psoriasis, the treatment regimen was changed from fluocinonide ointment to clobetasol propionate (Temovate®) 0.05% ointment BID and calcipotriene (Dovonex®) 0.005% ointment BID.

Other treatment options including oral retinoids, phototherapy, and biologic therapies were discussed at length with the patient. Due to economic and insurance restrictions, he was subsequently referred to a tertiary academic institution for possible enrollment in investigational treatment trials for psoriasis.

REFERENCES:

1. Bolognia JL, Jorizzo JL, Rapini RP. Dermatology 1st Ed. London: Mosby; 2003, p. 125-149.

2. Odom RB, James WD, Berger TG. Andrew’s Diseases of the Skin: Clinical Dermatology 9th Ed. Philadelphia: W.B. Saunders Company; 2000, p. 218-223.

3. Garman M, Tyring S. The cutaneous manifestations of HIV infection. Dermatologic Clinics. 2002 April; 20 (2): 193-208.

4. Papp KA. Etanercept in Psoriasis. Expert Opin Pharmacother. 2004 Oct;5(10): 2139-46.

5. Sobell JM, Hallas SJ. Systemic therapies for psoriasis: understanding current and newly emerging therapies. Semin Cutan Med Surg. 2003 Sep;22(3): 187-95.

6. Rook A, Wilkinson DS, Ebling FJG. Textbook of Dermatology 6th Ed. Oxford: Blackwell; 1998, p.1599.

Additional Comment:

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