by: Henry Foong FRCP,
M.S. is a 39-year-old Indian male who presents for evaluation and
treatment of a generalised scaling and erythema. He first noted patches
of scaling and erythema on the elbows and knees 2 years ago. This
subsequently spread to the scalp, face, trunk and extremities. He
is unemployed at the moment but has done odd labour jobs. M.S. is
the eldest of 5 siblings. His younger brother has similar problems
on the trunk and legs but to a lesser extent. The patient is married
and has 6 children.
Generalised dry scaly lesions on scalp, face, trunk and extremities.
The lesions were generally dark plate-like scales all over. Severe
diffuse alopecia was noted on the scalp. Nails were long and dystrophic.
Dr. Elpern's Comments:
I have seen cases of exfoliative erythroderma which looked like this
and actinic reticuloid (but the latter only in older individuals)
and also patients with hyper IgE syndrome. The alopecia is strange.
This is a worrisome case and I think he may need more history and
some lab studies - These would include cbc, chemistries, poss HIV
serology. Can the patient afford the lab studies?
would be to sit down with him and spend more time on the history before
committing him to the expense of costly lab studies - you may have
a clearer idea of what is going on then. Such as - is there a history
of atopy or preexisting skin disease. Please
give us follow-up - David Elpern
Due to financial constraints, I have advised the patient to be admitted
to the general hospital for further evaluation and treatment. Work
up for the patient was unremarkable with a normal FBC, blood biochemistry,
and CXR. VDRL/TPHA negative. Skin biopsy of the lesion showed features
consistent with psoriasis: acanthosis with hyperkeratosis and parakeratosis.
Acanthotic epithelium shows bulbous elongation of rete ridges. Upper
dermal lymphohistiocytic infiltrate were noted.
managed conservatively with moisturisers, topical betnovate ointment
and lesions cleared after 2 weeks in the ward.
Diagnosis: Erythrodermic psoriasis
had subsequently left for Singapore to look for a better job and had
not returned for follow up.
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