Rash and skin discoloration
A 52-year-old man went to a new family physician (FP) with a 4-year history of rash and a 1-year history of changes in skin color. He had white spots on his arms and back, and said the areas of rash were very itchy. The patient hadn’t been to a doctor in 2 years, but had been using over-the-counter hydrocortisone cream to stop the itching. He told the FP that no one else in his family was experiencing this. He also said he worked manual labor, drank 2 to 4 beers every night, and smoked a pack of cigarettes a day.
What’s your diagnosis?
The FP diagnosed plaque psoriasis as the cause of the erythema and scale. The FP suspected vitiligo or postinflammatory hypopigmentation as the cause of the discoloration. (It’s not unusual for patients with psoriasis to have vitiligo, as well.) The FP referred the patient to a dermatologist for a diagnosis, but never received feedback.
When diagnosing psoriasis, it’s crucial to determine if it’s accompanied by psoriatic arthritis. That’s because the presence of arthritis requires systemic therapy to prevent further joint damage. In this case, the patient denied having joint pain and morning stiffness.
Smoking tobacco and drinking excessive amounts of alcohol are both risk factors for psoriasis. The FP started treatment by discussing lifestyle changes and emphasizing the importance of abstinence from tobacco. While the patient wouldn’t set a quit date, he agreed to cut his intake down to half a pack of cigarettes a day. He also agreed to limit his consumption of alcohol to 2 beers a day. In addition, the FP prescribed a 454-g tub of 0.1% triamcinolone ointment to be applied twice daily. The ointment is more effective, but some patients may prefer the less greasy feel of a cream.
At a follow-up appointment a year later, the patient’s plaque psoriasis was under better control. His hands, however, showed extensive depigmentation. This confirmed the diagnosis of vitiligo, but the patient was not bothered by the appearance of it.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Psoriasis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 878-895.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com