Man's Condition Gets Out of Hand


This 46-year-old man’s skin disease has gotten so serious that he is essentially disabled. The problem started about six months ago, with joint pain that particularly affected his left ankle. Now, his hands are fissured and swollen to the point that he is unable to button his shirt or hold a fork. He is referred to dermatology by his attorney, who is helping him pursue possible disability benefits, for evaluation and treatment.

He has been seen by a variety of primary care providers, who have collectively prescribed topical triamcinolone 0.1% and several antifungal medications, including a two-month course of oral terbinafine. When those failed, he was treated with prednisone; at the start of the three-week course, there were signs of improvement but by the end, his hands were worse than ever.

The dorsal and palmar surfaces of the patient’s hands are covered with thick, white scales atop salmon-colored erythematous bases. Multiple fissures and marked edema can be seen. Seven of 10 fingernails are dystrophic, yellowed, and thickened.

The patient’s elbows, knees, and upper intergluteal area show less impressive involvement.

There is marked tenderness on palpation of the left Achilles insertion, made worse by dorsiflexion.

What is the diagnosis?

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