Spotting Psoriasis and Similar Syndromes: A Photo Quiz

Question 1:

A 34-year-old man was concerned about multiple nails that were rapidly becoming discolored and separated from the underlying tissue. He was sure he had a “nail fungus.” He knew he had psoriasis but failed to connect onychodystrophy to his underlying skin disease.

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Question 2:

A 56-year-old man sought medical attention because a rash suddenly appeared on his trunk and extremities. He had experienced a severe upper respiratory tract infection, which included pharyngitis, immediately before presentation. The eruption largely consisted of multiple small plaques. There was a notable paucity of large plaques.

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Question 3:

A 48-year-old construction worker has had joint pain and this worsening rash on his hands for 1 year. He attributed the symptoms to his occupational exposure. Possible causes included psoriasis, contact dermatitis, lichen planus, palmar keratoderma, and rheumatoid arthritis. The scaly erythematous plaques, subungual hyperkeratosis, and onycholysis pointed to psoriasis, with psoriatic arthritis and dactylitis.

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Question 4:

A 37-year-old man with chronic plaque psoriasis had been in a county jail where he was not exposed to sunlight for 18 months. About 40% of his body was affected. Physical examination revealed numerous areas of typical oval plaques with sharp, well-defined borders. Red papules that had coalesced into scales were noted. Most of the scaled areas were extremely dense, most notably on the extensor surfaces and the right anterior thigh.

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Question 5:

A generalized papulosquamous rash developed in this 4-year-old boy that began on his neck and head and then spread to his trunk. The skin on his hands and feet became thick and fissured. A unique “sandal-like” keratoderma that develops on the hands and feet is characterized by sharp margins. The primary and characteristic skin lesions are small, follicular reddish-yellow scaling papules that coalesce into plaques that form such that islands of normal-appearing skin are left.

Psoriasis was suspected, but the boy had typical pityriasis rubra pilaris.

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Question 6:

The 76-year-old man had many previous nonmelanoma skin cancers and 1 melanoma in-situ. The asymptomatic lesion depicted was on his left ankle. Absent a history of papulosquamous skin disease, such as psoriasis, a solitary, well-demarcated, bright-red scaly patch should suggest superficial basal cell carcinoma or in-situ squamous cell carcinoma. A small biopsy established the correct diagnosis: squamous cell carcinoma in-situ (Bowen disease).

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ANSWER KEY:

Question 1. A

Question 2. B

Question 3. E

Question 4. C

Question 5. C

Question 6. C