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 Table of Contents  
IMAGES IN RHEUMATOLOGY
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 84-85

Unstable psoriasis in the setting of psoriatic arthritis: A rare presentation


1 Department of General Surgery, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
2 Indushree Skin Clinic, Lucknow, Uttar Pradesh, India
3 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission20-Jun-2021
Date of Acceptance26-Aug-2021
Date of Web Publication22-Jan-2022

Correspondence Address:
Dr. Latika Gupta
Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_128_21

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  Abstract 


Keywords: DMARDs, glucocorticoids, guttate psoriasis, psoriatic arthritis, unstable psoriasis


How to cite this article:
Raj R, Saraswat A, Thomas KN, Gupta L. Unstable psoriasis in the setting of psoriatic arthritis: A rare presentation. Indian J Rheumatol 2022;17:84-5

How to cite this URL:
Raj R, Saraswat A, Thomas KN, Gupta L. Unstable psoriasis in the setting of psoriatic arthritis: A rare presentation. Indian J Rheumatol [serial online] 2022 [cited 2022 Oct 1];17:84-5. Available from: https://www.indianjrheumatol.com/text.asp?2022/17/1/84/336269



A 34-year-old man with psoriatic arthritis (PsA) and refractory anemia of chronic disease treated with glucocorticoids for 1 year returned with florid cutaneous lesions and fever of 2 weeks after abruptly stopping glucocorticoids. Physical examination revealed pallor, erythroderma, and widespread pink droplet-like skin lesions with overlying paper-thin plaques involving 50% of face, >90% of the trunk, limbs, palms, and soles [Figure 1], suggestive of unstable psoriasis. Healed sequelae of previous cutaneous lesions and onycholysis with subungual hyperkeratosis of toenails were present. Musculoskeletal examination revealed arthritis of the ankle, small hand joints, and swan-neck deformity, with the restricted terminal extension of the elbows and knees. He tested negative for HIV.
Figure 1: (a) Healed lesions on the face and neck (black arrows); (b) Extensive droplet-like salmon-colored lesions on the dorsum of the hand (white arrow), subungual hyperkeratosis of fingernails (yellow arrows), erythroderma and droplet-like lesions covered with white plaque (blue arrow), onycholysis of toenails (red arrow)

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While PsA mostly manifests classic chronic cutaneous plaque psoriasis, unstable psoriasis is seen in association with abrupt withdrawal of steroids and DMARDS, and infections.[1],[2] Unstable psoriasis represents an exacerbation of psoriatic disease and initially mimics guttate forms, presenting with diffuse small droplet-like papules. These lesions progress within days to weeks to enlarge or coalesce into larger plaques or evolve into pustular lesions or erythroderma.[3] PsA flares in HIV patients can present with an admixture of guttate and plaque types of lesions. This has particular implications in countries like India, where patient care is suboptimal due to the low affordability of treatment and rampant systemic corticosteroid abuse. As such, one can expect to encounter more cases with a similar picture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Naldi L, Peli L, Parazzini F, Carrel CF, Psoriasis Study Group of the Italian Group for Epidemiological Research in Dermatology. Family history of psoriasis, stressful life events, and recent infectious disease are risk factors for a first episode of acute guttate psoriasis: Results of a case-control study. J Am Acad Dermatol 2001;44:433-8.  Back to cited text no. 1
    
2.
Blok S, Vissers WH, van Duijnhoven M, van de Kerkhof PC. Aggravation of psoriasis by infections: A constitutional trait or a variable expression? Eur J Dermatol 2004;14:259-61.  Back to cited text no. 2
    
3.
Boyd AS, Menter A. Erythrodermic psoriasis. Precipitating factors, course, and prognosis in 50 patients. J Am Acad Dermatol 1989;21:985-91.  Back to cited text no. 3
    


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