This 59-year-old woman presented for evaluation of a chronic rash on her palms of several months’ duration. She described it as being intermittently itchy. She denied having rashes elsewhere on her body, but she did complain of having pain in the proximal joints of her fingers. There had been no changes in her medications.
Answer: PsoriasisSee the full case at Consultant360
Psoriasis is responsible for this rash. The patient’s nail pitting provides the clinical clue to the diagnosis.
Laboratory test results showed that she had an HIV RNA viral load of 98,550 copies/mL and a CD4 count of 174 cells/mm3. Upon further questioning, the patient admitted to poor adherence with her HIV medications and having engaged in unprotected sexual intercourse for past several months.
Psoriasis affects 2% to 3% of the population, and the estimated prevalence of psoriatic arthritis among these individuals is from 4% to 30%. Moreover, an estimated 10% to 55% of all patients with psoriasis have psoriatic nail disease. This means that approximately 7 million people in the United States have psoriasis, with from 150,000 to 260,000 new cases of psoriasis being diagnosed each year.
The pathogenesis of this disease is not completely understood. The epidermis is infiltrated by a large number of activated T cells, which appear to be capable of inducing keratinocyte proliferation. This is thought to contribute to an ensuing deregulated inflammatory process, with a large production of various cytokines.1
A systematic review of 90 studies confirmed that patients with psoriasis had a higher risk of ischemic heart disease, stroke, and peripheral arterial disease but also had a greater prevalence of risk factors for cardiovascular disease compared with control subjects.2 The dose-response relation between uncontrolled hypertension and psoriasis severity remained significant after adjustment for age, sex, body mass index, smoking status, alcohol use, comorbid conditions, and current use of antihypertensive medications. A greatly increased risk of chronic kidney disease was also associated with increasing severity of psoriasis.
While all 3 of the patients described here were initially treated with topical therapy, the concern as to whether psoriasis is a marker for increased morbidity and mortality due to systemic inflammatory mediators continues to be investigated.
1. Meffert J. Psoriasis. Medscape. http://emedicine.medscape.com/article/1943419-overview. Updated February 17, 2017. Accessed March 28, 2017.
2. Patel RV, Shelling ML, Prodanovich S, Federman DG, Kirsner RS. Psoriasis and vascular disease-risk factors and outcomes: a systematic review of the literature. J Gen Intern Med. 2011;26(9):1036-1049.