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51-Year-Old Woman With Severe Hyperpigmentation in Skin Plaques

Can you diagnose this case?

Rizvi SAA, Alvarez A, Alam R, Qureshi Z, Sikandar S, Khan S. [published online March 4, 2019]. Consultant360.

Signs and Symptoms

A 51-year-old African American woman with a more than 20-year history of severe plaque psoriasis presented to the clinic due to a flare-up of her symptoms, including moderate joint pain (but no muscle aches or weakness), enlargement of plaques, severe pruritus, flaking, and erythema. Her family history was noncontributory.

Physical Examination

At presentation, the woman appeared healthy, well-nourished, and well-developed. The patient’s height was 170.7 cm and weight was 95.7 kg, corresponding to a BMI of 34.1 kg/m2.

Her vital signs were normal. Her mood was normal; she was active and alert, and oriented to time, place, and person; and she was in distress as a result of her skin discomfort. Plaques were noted all over the body, along with hyperpigmented annular lesions with crusting and silvery scales (Figure). The rest of the physical examination findings were normal.

What’s your diagnosis?

Choose one to reveal diagnosis and discussion

Syphilis
Pityriasis alba
Psoriasis
Allergic contact dermatitis
Atopic dermatitis

Answer: Psoriasis

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Discussion

Psoriasis is a chronic inflammatory and immune-mediated disorder with skin, joint, and systemic effects that often causes emotional and psychosocial effects leading to poor quality of life.1-3 It is estimated to affect 2.8% of the population worldwide with marked ethnic heterogeneity.4 In the United States, psoriasis affects 1.4% to 4.6% of the population, although this percentage is much lower (0.45%-0.7%) among black patients, albeit with generally more extensive involvement.2 Many studies have provided evidence of a genetic predisposition; however, the inherence patterns as well as the contribution from genetic and environmental factors is still not known.5-7

The diagnosis is mainly clinical. Psoriasis is classified as mild, moderate, or severe, and the most common type is chronic plaque psoriasis, classified as papulosquamous with erythematous plaques and silvery scales.8 Postinflammatory hyperpigmentation is reported to be mediated by tumor necrosis factor α and interleukin 17, and spots fade away over time once the flare is over.9,10 In darker skin types, proper diagnosis of psoriasis can be challenging due to overlapping features with other skin disorders.11 It has been reported that African American patients experience a higher degree of dyspigmentation with extensive disease involvement compared with white patients,7 and patches may take 3 to 12 months to resolve.

Recent advancements in molecular medicine have improved our understanding of the immune-pathogenesis of psoriasis, and newer treatment options are available.12 Most patients respond well to topical therapy; however, patients with refractory and severe symptoms require systemic therapy.13

It is important for clinicians to be aware of known disparities in the diagnosis of psoriasis among various ethnicities and its effects on quality of life, thus necessitating customized and optimized treatment.

Outcome of the case

The patient was placed on a regimen of adalimumab (40 mg/0.8 mL) subcutaneous injection every 2 weeks; oral prednisone, 20 mg, twice a day; and topical calcipotriene cream, 0.005%, and fluocinonide solution, 0.05%, applied to the affected areas twice a day. Her symptoms had been improving significantly, and she makes follow-up visits as needed.

References

    1. Greb JE, Goldminz AM, Elder JT, et al. Psoriasis. Nat Rev Dis Primers. 2016;2:16082.
    2. Schön MP, Boehncke W-H. Psoriasis. N Engl J Med. 2005;352(18):1899-191
    3. Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Can Fam Physician. 2017;63(4):278-285.
    4. Yin X, Low HQ, Wang L, et al. Genome-wide meta-analysis identifies multiple novel associations and ethnic heterogeneity of psoriasis susceptibility. Nat Commun. 2015;6:6916.
    5. AlShobaili HA, Shahzad M, Al-Marshood A, Khalil A, Settin A, Barrimah I. Genetic background of psoriasis. Int J Health Sci (Qassim). 2010;4(1):23-29.
    6. Elder JT, Nair RP, Guo S-W, Henseler T, Christophers E, Voorhees JJ. The genetics of psoriasis. Arch Dermatol. 1994;130(2):216-224.
    7. Gelfand JM, Stern RS, Nijsten T, et al. The prevalence of psoriasis in African Americans: results from a population-based study. J Am Acad Dermatol. 2005;52(1):23-26.
    8. Dogra S, Mahajan R. Psoriasis: epidemiology, clinical features, co-morbidities, and clinical scoring. Indian Dermatol Online J. 2016;7(6):471-480.
    9. Wang CQF, Akalu YT, Suarez-Farinas M, et al. IL-17 and TNF synergistically modulate cytokine expression while suppressing melanogenesis: potential relevance to psoriasis. J Invest Dermatol. 2013;133(12):2741-2752.
    10. Santa María P, Valenzuela F, Morales C, De la Fuente R, Cullen R. Lentiginous eruption in resolving psoriasis plaques during treatment with ixekizumab: a case report and review of the literature. Dermatol Reports. 2017;9(2):7079.
    11. Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemiology, genetics, clinical presentation, and treatment nuances. J Clin Aesthet Dermatol. 2014;7(11):16-24.
    12. Nickoloff BJ, Nestle FO. Recent insights into the immunopathogenesis of psoriasis provide new therapeutic opportunities. J Clin Invest. 2004;113(12):1664-1675.
    13. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58(5):826-850.

Authors

Syed A. A. Rizvi, PhD, MS, MBA Hampton University School of Pharmacy, Hampton, Virginia

Annabelle Alvarez, MPH, MS-IV Nova Southeastern University, Fort Lauderdale, Florida.

Rehana Alam, DPM, MS-III Nova Southeastern University, Fort Lauderdale, Florida

Zafar Qureshi, MD UHI CommunityCare Clinic, Miami, Florida.

Sehrish Sikandar, MBBS UHI CommunityCare Clinic, Miami, Florida.

Salar Khan, BS University of Florida, Gainesville, Florida