Raafa Hayani MD, Baghdad, Iraq on Nov 10,
Though only one photo is apparent, it looks to me that this
case is psoriasis since there is fine silvery scales in the
external ear and the lesion of psoriasis sometimes presented
with single or very few lesions but surprisingly that lesion
was resistant to potent steroids so I suggest to repeat the
culture test for fungal infection and to try systemic antifungal
treatment before the use of a very potent steroids.
Joel Bamford MD, Duluth, MN, USA on Nov 10,
The excellent photos show a range of fresh erosions, hypopigmented,
non-inflammed healing areas as well as some that hint at dermal
infiltrate making me consider healing.
Given the macular appearance (description is of plaque on leg)
with superficial erosions and fine desquamating changes without
punctate bleeding to suggest psoriasis; I would first consider
artifact, self induced lesions, some being lichen simplex chronicus
accounting for the psoriasiform designation.
I would have to be open to any of the other papulosquamous lesions.
Khalifa Shaquie MD, PhD, Professor of Dermatology,
College of Medicine, University of Baghdad, Baghdad, Iraq
on Nov 11, 2005
This is a very interesting case. It is not pemphigus and unusual
to be psoriasis. Please try to exclude leprosy or secondary
syphlis. Repeat the biopsy,to be taken from the big annular
plaque on the leg.
Omid Zargari MD, Consultant Dermatologist,
Booali Medical Group, Rasht, Iran on Nov 13,
To me, the most likely diagnosis is still psoriasis, although
I agree with Dr. Bamford that some degrees of self-manipulation
is responsible for these atypical plaques in this patient. Regarding
the clinical pictures and sites of involvement, I cannot see
any obvious reason for putting pemphigus as the first (and sole)
Shahbaz Janjua MD, Consultant Dermatologist, Ayza Skin
and Research Center, Lalamusa, Pakistan on November
In my opinion DLE should be considered for the lesions involving
the ears, and hypertrophic lichen planus for lesions on the
lower legs. Antimalarials are used to treat both the conditions,
so a therapeutic trial would be worthwhile, especially when
the histopath findings were not helpful.
Abbas Alshammari MD, Doha, Qatar on November
Unfortunately,the presentation of this case in my opinion is
cloudy and confusing. I don't find any hint to put pemphigus
as a differential diagnosis. Again the author didn't use the
photos in proper way to help us in reaching correct diagnosis.
I suggest to re-evaluate the case including histopathological
views because psoriasiform pattern is a descriptive rather than
diagnostic term seen in many situations other than psoriasis.
Azad Kassim MD, Hasa, Saudi Arabia on November
"Good doctors are good observers". If you look to
the close view of the middle image you will find a characteristic
hypopigmented ring around the resolved plaques, this is called:
Woronoff Ring and it is very characteristic for lesions of psoriasis.
Maria Lorna Frez MD, Clinical Assoc Professor, Section
of Dermatology, University of Philippines, Manila, Philippines
on November 24, 2005
Taking into consideration all the information available my
primary diagnosis is still psoriasis. Suggest better pictures-
right angulation and histopath pictures. I am not sure but did
I see some scalp changes?
The exact duration of time Dovonex was applied was not mentioned.
Topical cakcipotriol especially on the legs will take some time
to take effect clinically. If Dovobet or Daivobet (calcipotriol
with betamethasone dipropionate ) is available it is a better
initial alternative esp for the legs. Tacrolimus (Protopic)
ointment does not work well on plaques without occlusion.