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