Hand pain and rash
A 44-year-old man presented to his new family physician (FP) with a 5-year history of rash and a 10-year history of pain in his hands. He said his finger joints were especially stiff in the morning. Plaques were visible on the dorsum of his fingers, hands, and wrists, along with large areas of involvement on his trunk and extremities. There was also nail pitting and onycholysis in some fingernails. The patient denied having any illnesses and was not on any medication. He had recently obtained health insurance for the first time in 5 years, so he had not received ongoing medical care during that time.
What’s your diagnosis?
The FP diagnosed psoriatic arthritis and psoriasis in this patient. The psoriatic arthritis had already caused swan neck deformities of multiple fingers, consistent with the mutilans subtype of psoriatic arthritis. The FP was aware that this patient needed to see a dermatologist and/or rheumatologist due to the severity of the arthritis.
Patients like this need systemic therapy with methotrexate, apremilast, or an anti-tumor necrosis factor alpha-inhibitor on an ongoing basis to both treat the arthritis and attempt to prevent further joint destruction. This will also treat the extensive plaque psoriasis that may accompany psoriatic arthritis. Most patients with psoriatic arthritis also have nail involvement (as did this patient), and it may respond to systemic treatment, as well.
Since systemic treatment is frequently outside the FP’s scope of practice, referral to a specialist is essential. The FP can, however, start topical therapy for the plaque psoriasis. This can be initiated with mid- to high-potency topical steroids.
It may be tempting to give a patient like this oral prednisone or an intramuscular steroid, but such therapy should be avoided because it can result in rebound pustular psoriasis. (These treatments do not work well enough to take the risk.)
In this case, the FP prescribed a 60-g tube of 0.05% clobetasol ointment to be applied to the worst areas, along with a 1-lb tub (454 g) of 0.1% triamcinolone to be applied to the other plaques. The patient was glad to receive treatment for his psoriasis and looked forward to seeing a specialist for treatment of his arthritis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Psoriasis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 878-895.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com