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Acute onset of rash and oligoarthritis

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A 29-year-old man sought treatment at our clinic for an extensive rash he’d developed the month before. The rash was on his scalp, umbilicus, glans penis, palms, and soles of his feet. He reported swelling in his left knee and his fourth toes bilaterally that was exacerbated by weight bearing. During the 2 days prior to his visit to the clinic, the patient said he’d had a fever and night sweats; he denied ocular symptoms, GI complaints, dysuria, or penile discharge.

When asked about his sexual history, the patient noted that he’d had unprotected intercourse with a woman a year earlier that resulted in pain on urination and resolved on its own. Other than a resolved case of oral thrush, the patient had a noncontributory past medical history, took no medications, and had no family history of psoriasis.

A physical exam revealed circinate, scaly, and erythematous plaques covering his entire scalp ( FIGURE 1 ). The patient’s conjunctiva and oropharynx were clear. His fingernails showed hyperkeratosis, subungual debris, and nail fold erythema, without pitting. He also had bilateral swelling of the distal interphalangeal joints of his index fingers.

The patient’s umbilicus had a scaly erythematous plaque, while there were confluent erythematous plaques in the groin area, and on the glans penis. There were also similar erythematous plaques in the axilla and inguinal folds; plaques on the lower extremities had a thicker layer of scale. The patient’s feet had crusted plaques on the plantar surface, hyperkeratotic nails with thick subungual debris, and swelling and tenderness of the fourth toes bilaterally ( FIGURE 2 ).

Circinate plaques

A 29-year-old man with circinate plaques on his scalp.

Hyperkeratotic nails, swollen toe

The patient had subungual hyperkeratosis, onycholysis, and dactylitis of the fourth toe.

What is your diagnosis?


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