A Rash in Rehab – Pustular Psoriasis: A Case Report

Case Diagnosis: 80-year-old female with pustular psoriasis

Case Description or Program Description: An 80-year-old female with past medical history significant for Steven-Johnson Syndrome, heart failure, hypertension, hyperlipidemia, type 2 diabetes mellitus, atrial fibrillation, and chronic kidney disease presented to IPR with right sided-weakness in the setting of acute punctate left temporal cortical infarctions. On admission exam, she was noted to have an erythematous rash which worsened over the course of her admission. She was treated with azithromycin for otitis media as well as a course of prednisone for the rash and extreme pruritus

Setting: Academic Inpatient Rehabilitation and Acute Care Hospital

Assessment/Results: Due to worsening blood sugar control and worsening rash with desquamating skin, the patient was returned to the acute floor. A dermatologic evaluation was performed with differential diagnoses that included erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug eruption, staphylococcal/streptococcal scalded skin, and pustular psoriasis. A skin biopsy was done showing acute generalized exanthematous pustulosis with no interface damage seen. She was treated with high dose oral steroids, Diflucan, Claritin, and famotidine with near resolution of rash.

Discussion (relevance): Pustular psoriasis is a variant of psoriasis vulgaris and is a rare, immune-mediated systemic skin disorder characterized by yellowish pustules on an erythematous base. There are a variety of clinical presentations and distribution patterns as well as generalized and localized subtypes. It affects both children and adults in a bimodal age distribution with Asians being more affected than Caucasians. Women and men are affected equally. Pustular variants of psoriasis represent approximately 1% of all clinical cases of psoriasis vulgaris.

Conclusions: Accurate identification of the etiology of skin lesions is important for prompt and precise treatment and prevent associated complications including hypocalcemia, septicemia, hyperthermia, liver damage, acute renal failure, and malnutrition. Differential diagnoses of pustular psoriasis include drug eruption reaction, pemphigus vulgaris, impetigo, erythroderma, and acute cutaneous lupus, among others