MBBS Short case: Psoriasis vulgaris
For undergraduate medical students
Requested and specially dedicated to my ex-students from Universiti Malaya.
Question: Please examine the skin of this patient.
Scenario: Patient with plaques on the elbow
Objectives:
1. Demonstrate that it is indeed psoriasis plaques
– Demonstrate the typical morphology of psoriatic plaque
– Demonstrate the typical distribution of psoriatic plaque
2. Look for other system involvement
– psoriatic nail changes
– psoriatic arthropathy
3. Look for other associated condition
– Metabolic syndrome (diabetes mellitus, hypertension, central obesity)
– Ischaemic heart disease
– Psychiatry disorder (alcohol addiction, tobacco usage, depression etc)
4. Look for common treatment complications
– Methotrexate complication
General observation
– Central obesity
– Any glaring abnormalities
Examination of the skin lesions
– Description of the skin lesions
- well defined
- erythematous
- silvery scale
– Description of the typical distribution
- Extensors
- look out for Koebnerisation (psoriatic plaque over trauma/scar area)
– Examination of other ectoderms
- Nails (Look for psoriatic nail changes- oil-spot signs, subungual hyperkeratois, nail pitting, total nail dystrophy
- Mucous membrane
- Hair
Examination of the joints
– Look for medium joint effusion/pain/tenderness (most common arthropathy is the oligo/mono-arthritis involving medium joint)
– Look for small joint involvement (for rheumatoid arthritis like arthritis, DIP joint involvement or arthritis mutilans)
ps: note if the arthritis is active or quiescent (active- tenderness, effusion and increase in temperature as opposed to quiescent- only deformities)
Complete the examination
– Examine the spine for spondyloarthropathy
– Examine the blood pressure (hypertension)
– Examine the fundus for diabetic and hypertensive changes
– Examine the GI system for inflammatory bowel syndrome (associated disease)
– Examine the lungs for pulmonary fibrosis, liver dysfunction, haematology system (side effect of methotrexate)
Conclusion
Patient has
– Psoriasis vulgaris
– with nail/joint involvement (p.s. if joint, what type of joint involvement, if there are functional limiting deformities)
– with other associated disease on examination
– with other conditions associated with treatment of psoriasis
Example:
Mr X has psoriasis vulgaris with nail involvements as well as active oligoartritis of his knee and ankle joints. He also has central obesity and median sternotomy scar suggesting a possible previous cardiac bypass surgery. Both conditions are associated with psoriasis vulgaris.
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