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51-Year-Old Female with Hand Eczema

Can you diagnose this case?

David L. Kaplan, MD-Series Editor

Signs and Symptoms

This 51-year-old woman presented with a 2-year history of chronic hand eczema that would partially respond to topical corticosteroids, only to recur. She denied any new exposure history. She had not had the condition in the past.

What explains this recurrent rash?

Choose one to reveal diagnosis and discussion

Contact dermatitis
Atopic dermatitis
Lichen planus

Answer: Psoriasis

See the full case at Consultant360

The patient had psoriasis, which originally had been diagnosed and treated as eczema.

Note: All of the approaches listed above—patch testing, KOH prep testing, and examination of the fingernails, elbows, knees, and feet—are important maneuvers in making the correct diagnosis of psoriasis. The fingernails will show possible signs of psoriasis or lichen planus. Tinea pedis of the feet could result in dyshidrosis and yield KOH prep test results that are positive for fungal infection.

On closer physical examination, this patient also had involvement of her elbows, which allowed the diagnosis of psoriasis to be made. The well-demarcated lesions on the palms support the diagnosis. Nevertheless, it is important to remember that patients can have overlapping diagnoses.

While topical treatment is the safest option for psoriasis, patients with extensive involvement often require systemic therapy. This is especially true for difficult-to-treat areas such as the hands. This patient was started on topical corticosteroids alternating with calcipotriene.