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Finger pain and swelling

A 45-year-old man who was being seen by a dermatologist for longstanding psoriasis went to see his family physician (FP) because he’d begun experiencing finger pain and swelling. The patient, who had a history of hepatitis C, noted that his fingernails had recently begun crumbling and his fingers were stiff in the morning.

What's your diagnosis?


The FP diagnosed psoriatic arthritis (with dactylitis and significant distal interphalangeal joint [DIP] involvement) in this patient. Both of the patient’s hands were involved, but his left hand was worse. The condition of the patient’s nails was not surprising, given that almost all patients with psoriatic arthritis have nail involvement.

Radiographs of the patient’s hands showed periarticular erosions and new bone formation. There was also telescoping of the third DIP joint.

Treatment choices for psoriatic arthritis include methotrexate and the new biologic anti-tumor necrosis factor (TNF)-α medications.

This patient was referred to a rheumatologist. Methotrexate treatment was avoided because of the liver toxicity issue in a patient with active hepatitis C. The rheumatologist started him on the biologic adalimumab with injections every 2 weeks (not contraindicated with hepatitis C).

Photo courtesy of Ricardo Zuniga-Montes, MD and text courtesy of Richard P. Usatine, MD. This case was adapted from: Chumley H, Usatine R. Arthritis overview. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:562-568.

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