Photo Rounds

Red rash and finger deformities

A 42-year-old man sought care for a red rash and arthritis in his fingers that had been bothering him for some time. The patient was homeless, uninsured, and couldn’t work because of the condition of his fingers. He indicated that 10 years earlier, he’d been told that he had a skin disease, but he hadn’t been treated in years.

What's your diagnosis?


The family physician (FP) diagnosed plaque psoriasis with psoriatic arthritis mutilans in this patient, a severe, deforming type of arthritis that usually affects joints in the hands and feet.

His psoriatic arthritis had caused swan-neck deformities with involvement of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. Both hands were involved, but the patient’s right hand was worse. Radiographs of the hands showed periarticular erosions with new bone formation.

The patient was clearly disabled based on the severe deformities of his hands. Appropriate treatment to prevent progression of the mutilating arthritis would require systemic medications that need monitoring with blood tests (and health insurance to afford the medications and lab tests).

The FP treated the patient with topical steroids and oral nonsteroidal anti-inflammatory drugs at the shelter clinic. The patient was given information about seeing a caseworker the following morning. Choices for therapy included methotrexate and the new biologic anti-tumor necrosis factor (TNF)-α medications.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chumley H. Ankylosing spondylitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:580-584.

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