Case Report Quiz: Psoriasis Diagnosis Second Opinion

Close-up of well-demarcated plaques with silvery scale in chronic plaque psoriasis

Image courtesy of DermNet

Ezra is a 28-year-old Caucasian male presenting to my practice for a second opinion on his recent diagnosis of plaque psoriasis on his arms and legs. He was seen at another dermatology practice and prescribed Otezla (apremilast; Amgen) but had to discontinue due to side effects of insomnia and diarrhea. He reports that he was also prescribed fluocinonide cream, triamcinolone cream, and calcipotriene cream but denies any consistent improvement. Ezra reports that lesions have only become worse, are very itchy, and are starting to spread. He states that the worst area is on his left leg, where he has also been experiencing swelling for the past 2 months. 

When examining Ezra’s skin, you note well-defined erythematous scaly plaques with well-defined, serpiginous, raised borders and yellow crusting on the anterior shins and forearms. He has 10% BSA affected. His lower left leg has +2 pretibial and pedal edema. There is no tenderness to palpation or warmth upon exam.