Unusual form of psoriasis in a 48-year-old woman

presented by

Haitham Algari MD

New York, NY, USA

on November 9, 2005

Department of Dermatology, Mount Sinai School of Medicine, New York, NY, USA

Abstract A 48-year-old woman presented with psoriasiform lesions on her lower extremities and ears of 6 months duration. Differential diagnoses include psoriasis and pemphigus foliceous.
48-year-old woman
6 months
lower extremities

48-year-old African-American woman presented with history of skin lesions limited to the lower extremities and both ears of 6 months duration. The lesions were persistent, treated as impetigo by her general physician with multiple courses of oral antibiotics without any benefit. There was no significant past medical history. She is a housewife. There was no history of skin disease in the family.
She was also treated by several dermatologists without improvement. Treatment included potent topical corticosteroids and Protopic (tacrolimus) ointment for couple of months. Dovonex ointment and Bactroban ointment were also tried for considerable period without any benefit.

Physical Examination

Right leg medial aspect showed single plaque 6 x 6 cm superficial plaque with fine scaling. Left leg showed 6 well-defined annular lesions on different stage of healing, cover with fine scaling. The lesions were asymptomatic. Both ears had whitish fine silvery scaling. Her palms, soles and nails free. Oral and genital lesions free.



Laboratory Data

Investigations including CBC, ESR, LFT, U/E/Cr/glucose were normal.
ANA, antiDNA and ENA tests were negative.
Hepatitis (C and B) markers and HIV Ab were negative.
RPR pending.
Culture, gram stain, KOH: are negative for bacteria and fungus.


A repeat skin biopsy on the left and right leg showed psoriasiform dermatitis. No feature suggestive of bullous disease. Direct immunofluorescence test was negative.

Diagnosis Unusual form of psoriasis / Pemphigus foliaceus ?
Reasons Presented

Diagnosis and management of this patient.


What is the most likely diagnosis?

How do we arrest the progress of the skin lesions?

How do we manage this patient?




Comments from Faculty and Members

Raafa Hayani MD, Baghdad, Iraq on Nov 10, 2005

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, 2005

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, 2005

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) differential.

Shahbaz Janjua MD, Consultant Dermatologist, Ayza Skin and Research Center, Lalamusa, Pakistan on November 13, 2005.

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 16, 2005

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 19, 2005

"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.

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