Photo Rounds

Extensive rash and joint pain

A 55-year-old man presented to his family physician (FP) with a one-month history of extensive rash and pain in his fingers and wrists. He said he’d had dry skin on his elbows before, but nothing like this large rash had ever occurred. The patient also said he had experienced some morning stiffness in his hands and wrists over the past year, but this was the first time it hurt to move them. He said that his blood pressure was under control, with no recent change in medications. The FP noted that the patient's skin was very dry with dark scaling. There was also faint pink coloring to the skin around the patient’s hands, as well as swelling around multiple joints and tenderness at the wrists. A closer look at the patient’s fingernails showed pitting, onycholysis, and oil spots.

What is your diagnosis?


Based on the patient’s tender finger and wrist joints and exfoliation of skin, the FP diagnosed erythrodermic psoriasis, although the patient’s dark skin made the erythema less visible. The patient was not systemically ill; however, the FP recognized that he would need systemic therapy for the arthritis and severe skin manifestations and referred the patient to a dermatology specialist.

The dermatology specialist agreed to see the patient the next day. She ordered the following lab tests: complete blood count (CBC), chemistry panel, QuantiFERON TB gold, hepatitis C antibody, and hepatitis B surface antigen, surface antibody, and core antibody. She also ordered bilateral hand films, which showed early juxta-articular erosions (consistent with psoriatic arthritis). Because of the strong skin, nail, and joint evidence, the dermatology specialist determined a biopsy was not necessary.

The patient was instructed to apply 0.1% triamcinolone ointment to his entire body using the wet pajama technique overnight. At follow-up, he said his skin felt better, but his joints did not. The dermatology specialist reviewed the lab results and explained to the patient that the 2 best options were oral methotrexate weekly or an expensive injectable biologic agent. Because most health insurance companies now require that the patient fail a less expensive agent such as methotrexate before trying the biologic, the decision was made to start with methotrexate. Within a month, the patient's skin was remarkably better and his joint pain and stiffness had improved significantly.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Henderson D. Erythroderma. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 915-921.

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