History: This 59 yo disabled man has had a resistant intertrigo for ten years. He was referred by his PCP because he did not respond to miconazle and Nystatin. Meds include oral hypoglycemics, metoprolol, HCTZ, statins.
O/E: Erythematous plaques covering groin, genitalia, axillae. Complete exam revealed erythema and crusting in gluteal cleft in addition (no one had looked there).
Clinical Photo(s)
Great T-shirt!
Gluteal Cleft
Lab: KOH prep negative
Histopathology: Biopsy Pending
Diagnosis or DDx: Inverse Psoriasis
Questions/Comments: This patient was followed for a yeast intertrigo for ten years by his physicians. It was assumed to be Candida because of his diabetes. The tip off was the sharp margination and the scale. When I checked the gluteal cleft, that clinched the diagnosis. We'll see if the biopsy confirms the clinical diagnosis. In addition, it is known that beta-blockers can exacerbate psoriasis and his metoprolol may be playing a role.
Reason(s) Presented: For interest. If one thinks of the diagnosis one can do the appropriate test: a simple punch biopsy.
References:
Clinical analysis of 48 cases of inverse psoriasis: a hospital-based study.
Eur J Dermatol. 2005 May-Jun;15(3):176-8.Wang G, Li C, Gao T, Liu Y.
Department of Dermatology, Xijing Hospital, Fourth Military Medical University,
15 Changlexi Road, Xi'an 710032 China. xjwgang@fmmu.edu.cn
Inverse psoriasis, rare in clinical practice, refers to psoriasis only or mainly
occurring at flexural sites, such as the axilla, antecubital fossae, popliteal
fossae, and inguinal creases. It is also known as flexural psoriasis. With a
total collection of psoriatic cases from September 2002 to December 2003 at
Xijing hospital, we made a retrospective analysis of the disease history,
clinical characteristics, and treatment of the patients affected with inverse
psoriasis. The results showed that the major clinical manifestations of inverse
psoriasis were sharply demarcated erythematous plaques with varying degrees of
infiltration and minimal or no scales. Affected areas often involve the groin,
axilla, genitals, and umbilicus. The disease responds well to the narrow band UVB
therapy. Compared with common psoriasis, inverse psoriasis has similar and unique
characteristics in terms of the affected areas, clinical symptoms, and responses
to the treatment.
1 comment:
I agree this is classical flexural psoriasis. The lesions were bilateral, symmetrical, scaly and plaque- like with well demarcated margin. There were no satellite lesions at all. Possible therapeutic agents would include topical calcipotriol, low potency topical corticosteroids and perhaps topical tacrolimus. Striae is a potential complication if high potency corticosteroids are used. Is there a role for NBUVB or oral systemic agents like methotrexate if topicals does not work??
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