Man's Condition Gets Out of Hand

DISCUSSION
Psoriasis can affect one or more areas, typically the hands, scalp, genitals, or feet. When it’s focused in one area, as in this case, it can be baffling to diagnose; sometimes it’s hard to see the forest for the trees. But because the condition affects almost 3% of white Americans, you’ll see it regularly—if you’re looking for it.

Nearly 25% of patients with psoriasis eventually develop psoriatic arthritis (PsA), which not only affects the joints but also can cause complications such as enthesitis, or inflammation of the entheses (the sites of insertion of the tendon into bone; eg, the Achilles). This can be confused with plantar fasciitis, which this patient had been previously diagnosed with.

This diagnosis could have been proved or disproved by a KOH prep (which would have shown evidence of fungal disease) or a biopsy (which would have shown fused rete ridges, microabscesses at the papillary tips, hyperkeratosis, and parakeratosis). Providers should first establish a firm diagnosis to dictate effective treatment. In this case, a visual diagnosis was possible.

Given the severity of the problem, the patient was started on a biologic; he showed vast improvement within a week. He was referred to rheumatology for evaluation and management of PsA, and the severity of his disease was communicated to his attorney.

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TAKE-HOME LEARNING POINTS

• In some cases, psoriasis can be isolated to the hands, feet, genitals, or scalp, complicating detection of the condition.
• Almost 25% of patients with psoriasis develop psoriatic arthritis (PsA), which can manifest with dactylitis, arthritis, or enthesitis.
• Left untreated, PsA is potentially debilitating.
• Establishing a firm diagnosis with KOH prep or biopsy will dictate effective treatment.