Case 1:
A 62-year-old woman presented to our dermatology clinic with a 4-year history of psoriasis. She was under topical treatment with corticosteroids and calcipotriene and most of her lesions had responded properly to the topical treatment resulting in significant recovery of psoriatic lesions. Although the patient complained of the lesion on her right lower extremity that had not responded to the treatment. She denied using any systemic medications. On physical examination, erythematous, scaly, indurated and mildly pruritic papules and plaques were noted on her right thigh and buttock that overlapped with L2 and L3 dermatomes (figure 1A-B-C). Scattered few guttate lesions were observed outside the area of primary or adjacent dermatomes. Affected body surface area was approximately 10%. Mucosal membrane, nail and joint were spared. The patient had no familial history of psoriasis. Vital signs and routine laboratory tests were in normal range. Since these lesions were resistant to topical treatments, we decided to initiate systemic treatments and plan a skin biopsy. Pathological findings from skin lesion revealed epidermal acanthosis and hyperproliferation with elongated and club-shaped dermal papillae. In the papillary dermis the capillaries had increased in number and length and had tortuous appearance. Edema was seen especially at the upper parts of the papillae. There was a mixed perivascular infiltration of lymphocytes, macrophages and neutrophils. The accumulation of neutrophils within a spongiotic pustules in the stratum cornenum, surrounded by parakeratosis, as a micro abscess of Munro was seen (figure 2A-B). These features consisted with psoriasis. As the patient’s dermatomal skin lesions did not resolve by topical treatment, methotrexate (15mg/weekly, single dose, oral) was administered for her. The use of folic acid supplementation and laboratory tests were also considered. After 12 weeks of treatment no significant changes in PASI score and distribution of the lesions were seen and patient was not satisfied. She rejected to use biological treatment or phototherapy. Acitretin (0.5mg/kg/day) was added to the previous treatment with very careful monitoring because of the risk of sever hepatotoxicity. 8 weeks after this treatment the patient was visited, and skin lesions had improved significantly, and she was satisfied (figure 3).
Figure 1.A,B,C
Figure 2.A,B
Figure 3