State Medical and Pharmaceutical University

„Nicolae Testemiţanu”

Department Of Dermatovenerologie

Head of Department Mircea Betiu

Name : Nasreena Kolliyil Valli
Grup : M1856
Year : 2024
Faculty : Medicina 2

CASE HISTORY

Date of curation : 17-02-2024

- Chisinau 2013 -

1
 CLINICAL EXAMINATION

I. PASSPORT DATA
Name,Surname: Ivanus Adward
Age : 50
Sex : Male
Adress : Floresti M. Costin
Ocupation : Security
Data of hospital admission : 12-02-2024
Hour : 09:20
Admission diagnosis : Psoriasis Vulgaris

CLINICAL DIAGNOSIS.

Psoriasis Vulgaris

II. Complaints
At the admission day:

Prescnce of widespread skin lesions on scalp, trunk, extensor part of upper and lower limbs accompanied by moderate
periodic itching. Pain in the joint of upper and lower limb (elbows, distal interphalangeal joints in the hands, knees,
talocrural).

III. History of present illlness

Suffered from psoriasis for twenty years. When skin lesions first appeared after psychoemotional stress. Periodically
outpatient and inpatient treatment follows. The last hospitalization in January 2023. One month ago, the condition worsened,
new disseminated lesion appeared. Arthralgia became more pronounced. He is admitted to SDMC for treatment.

2
 1. Biographic data IV. Personal history
Satisfactory living condition.

2. Sexual history

3. Comorbidities
Hypertension grade 2.
Chronic calculus cholecystitis.
Chronic viral Hepatits B.
Minimal activity.

4. Harmful habits – No smoking and no alcohol.

5. Family history
Two children suffering from psoriasis

3
 V. GENERAL HABITUS.

1. Inspection.

General state : Medium severity

Consciousness : Clear
Pozition : Active
Facies
Constitution : Hypersthenic height : 172 cm weight : 104kg
Skin, mucous membranes and skin appendages
Normal.

Hypodermis :
Edema :
Lymphatic nodes : Normal. Enlarged and not painful
Bone : Pain at palpation : Pain and limitation of movement.

4
 VI. DERMATOLOGIC EXAMINATION (status localis)

_A.Four cardinal features: _

1. Distribution of the lesions: Disseminated.
a. Extent or involvement: Scalp. Upper and lower limbs.

b.Pattern: Silver White Scaly Appearance

c.Characteristic location: Extensors.

2. Type of lesion: Multiple erythematous infiltrative covered plaques.

3.Shape of individual lesions: Well defined plaques and papules.

4.Arrangement of multiple lesions: Bilaterally symmetrical.

_B. Three major characteristics:

1. Color: Salmon coloured.
2. Consistency and feel of lesion:
Indurated.
3. Anatomic components of skin primarily
affected:
Upper and lower limbs and Scalp.
C. Special procedures for dermatologic diagnosis:
1. Palpation of the lesion: Grattage test
2. Diascopy or vitropressure:

5
 3. Raclage of lesions:

VII. CARACTERISTICS OF DERMATOSES WHICH PATIENT HAS.

Plaque psoriasis. The most common type of psoriasis, plaque psoriasis causes dry, itchy, raised
skin patches (plaques) covered with scales. There may be few or many. They usually appear on
the elbows, knees, lower back and scalp. The patches vary in color, depending on skin color. The
affected skin might heal with temporary changes in color (post inflammatory hyperpigmentation),
particularly on brown or Black skin.

PRESUMPTIVE DIAGNOSIS

Psoriasis Vulgaris.

INVESTIGATION’S LIST.
1. CBC
2. Histopathology
3. X-Ray
4. Biopsy

DIFFERENTIAL DIAGNOSIS.

Eczema
Tinea corporis,
Pityriasis rosea,
Secondary syphilis,
Lichen planus,
Bowen Disease,
Nummular Dermatitis,
Erythema Annulare Centrifugum,
Seborrheic dermatitis,
Lupus erythematosus

6
 CLINICAL DIAGNOSIS, ARGUMENTATION

The commonest pattern

• Single or multiple red plaques (papules) varying from a few millimeters to several centimeters in diameter
with a scaly surface
• Psoriatic step-by-step triad obtained by scraping:
- silvery (stearin) staining
- terminal (wet) plate
- cappilary-point haemorrhage (Auspitz sign)
• Predilection for extensor surfaces: the knees, the elbows and the base of the spine
• Lesions are often symmetrical
• The scalp and nails are often affected and the arthropathy may also occur
• Psoriatic plaques may appear at the site of trauma or scarring – Koebner or isomorphic phenomenon

7
 VIII. DISEASE EVOLUTION

Psoriasis is a model disease in dermatology. It is a common disease that affects at least 2 to 3 % of the
population. It is an illness characterized by an excessive reaction of the skin, in term of proinflammatory
cytokines release, to no specific attacks: these attacks can be immunological, mechanical, metabolic,
drug-induced or psychological. This excessive reaction is characterized by epidermal proliferation
combined with incomplete terminal differentiation, as well as an inflammatory response responsible for
the chronic nature of the lesions. The way to understand psoriasis is therefore to reach a better
appreciation of the messages that enable the skin cells to initiate an inflammatory response, and by better
understanding the way in which the inflammatory cells responsible for innate and acquired immune
responses are capable of bringing about proliferation and abnormal epidermal differentiation.

It started 20 years back on scalp with mild itching, at that time no family history were there. Later during
winter it aggravated, then in the summer the scaling reduced.

One year back due to aggravated symptoms he visited hospital and treated by corticosteroid that leads
disseminated psoriasis.

8
 IX. PRESCRIPTIONS AND PROGNOSIS
Topical therapy emollients: l-2% salicylic acid;
anthralin (Dithranol)-from 0,1% to 10% to 20%;
vitamin D3 (Calcipotriol/calcipotriene and tacalcitol);
corticosteroids;
retinoids: Tazarotene-0,1% gel in monotherapy;
topical immunomodulators and immunosuppressive drugs: Cyclosporine A topically;
Tacrolimus oinment, 5-fluorouracil cream/ solution;
UVB - 3 10-3 12 nm;
UVA- 320-400 nm;
lasers; hypertermia.
Systemic therapy: cytotoxic drugs (methotrexate);
retinoids Etretinate and Acitretin;
macrolide immunosuppressants: Tacrolomus, Pimecrolimus, Alephacept, Etanercept;
PUVA therapy;
Climatotherapy.

EPICRISIS
Psoriasis is a common, genetically determined, inflammatory and proliferative disorder of the skin, the most characteristic
lesions consisting of chronic, sharply demarcated, dull-red, scaly plaques, particularly on the extensor prominences and in the
scalp. Morphological variants are common. An assessment of any patient with psoriasis should include disease severity, the
impact of disease on physical, psychological and social well-being, whether they have psoriatic arthritis, and targeting
modifiable risk factors for cardiovascular disease.
Affects around 3% of the population
It is uncommon in certain populations such as oriental people, native American Indians and West Africans
Both sexes are equally affected.
Recent research suggests that psoriasis is an autoimmune disease
Abnormally large numbers of T-cells trigger the release of cytokines in the skin causing the inflammation, redness, itching
and flaky skin patches characteristic of psoriasis
Genetic factors are important, especially in the younger age group - a family history is present in 40-50% of cases and up to
75% if onset is before age 20
There is a high concordance in monozygotic twins and lesser (15-20%) in dizygotic twins
Lifetime risk - 4% if no family history, 28% if one parent affected, 65% if both parents affected
Stress - is strongly associated with psoriasis
Alcohol - heavy drinking is more common in patients with psoriasis. Excessive alcohol may have a direct effect on psoriasis,
in addition, reduced compliance with treatment is likely to exacerbate symptoms
Smoking - is a risk for both palmoplantar pustulosis and chronic plaque psoriasis
Trauma - psoriasis can occur at the site of skin injury (Köebner phenomenon)
Streptococcal infection, especially of the throat is well known to provoke guttate psoriasis
Severe or recalcitrant psoriasis is an identified HIV indicator condition
Drugs - a wide range of drugs are said to aggravate psoriasis. The most notable associations include lithium, certain anti-
malarials such as hydroxychloroquine, terbinafine, beta-blockers, TNF-inhibitors, and interferons

9
Pregnancy - if psoriasis alters it is more likely to improve in pregnancy but get worse postpartum
Sunlight - although sunlight is generally beneficial, a small minority have symptoms provoked by strong sunlight.

Skin
Psoriasis may develop at any age although it most frequently presents in young adults as well as in the sixth and seventh
decades
It is generally asymptomatic although some patients experience itch
Psoriatic arthropathy
Recent studies suggest that the prevalence of psoriatic arthritis in patients with psoriasis may be up to 30%
There is a strong link with nail disease
All patients should be assessed for psoriatic arthropathy (for example by using the PEST score) at the time of diagnosis of
psoriasis, and then annually - early intervention can reduce joint damage. Refer to related chapter on Psoriatic arthritis for
more information

Morphology
Most cases of chronic plaque psoriasis are described as large plaque psoriasis or small plaque psoriasis
Plaques are ruby-red, and well-defined with a silvery (or grey in skin of colour) surface scale. The plaques can join together
to involve very extensive areas of the skin particularly on the trunk and limbs
Auspitz sign - when adherent psoriatic scales are scraped or picked off pinpoint bleeding, known as the Auspitz sign, may
occur from capillaries which undulate vertically throughout the thickened psoriatic skin
Lesions on lower legs may be less typical

10