This case study describes a 27-year-old Egyptian housewife who presented with a 5-month history of pain and swelling in her small joints. Her condition progressed over 3 months to involve both wrists, fingers, and ankles. Examination found tender, swollen joints and limited range of motion. Tests showed elevated inflammatory markers. She was initially diagnosed with seronegative rheumatoid arthritis but later developed nail lesions suspected to be psoriatic, leading to a diagnosis of psoriatic arthritis. Her joint symptoms improved with treatment but she was referred to a dermatologist for further evaluation of her nail changes.

2. Short Case
Ahmed EL-Belasy
MSc Rheumatology
Alexandria University
Egypt

3. Personal History
• 27 years old , housewife.
• complaining of
o Pain and swelling of right wrist and small joints of
both hands of 5 month duration .

4. Present History
• Condition started 5 month ago by gradual onset of pain
, swelling of small joints of both hands and right wrist.
• She had medical treatment ( NSAIDs ) with no
improvement.

5. Present History
• 3 month later the condition progressed to include
pain and swelling of both wrist joints , MCPs , PIPs of
both hands and bilateral ankle joint pain.
• She has morning stiffness lasting for ½ hour.
o There was no fever.
o No ocular manifestations.
o No chest or cardiac complains.

6. Drug History
• Diclofenac 150mg MR Tab
Past History
• No Hypertension
• No DM
once/day
orally

7. Family History
• Parents : negative consanguinity.
• Irrelevant family history.

8. Examination
• General condition is good
• Vital signs :
o Pulse : 78 / min regular equal on both sides
o B.P : 120/ 80 mmhg
o Temp : 36.8 C
o R.R : 18/ min

9. Examination
• Head and neck:
o Clinically free
• Chest examination:
o Clinically Free.
• Heart :
o Clinically Free.
• Abdomen:
o Clinically Free.
• Neurologically :
o clinically Free
• Skin lesions:
o Clinically free

10. Joints Examination
• Tenderness of :
o Bilateral Wrist
joints.(swelling)
o Bilateral MCP joints.
o Bilateral PIP joints.
o Bilateral ankle joints.
Tender swollen joints.
Tender joints.
o ROM is limited due to pain.

11. Laboratory Investigations:
Routine
Investigations
Hb : 11.2 gm
WBC: 5,300
PLT: 279.000
S.Creatinine: 0.8 mg/dl (N. 0.5-1.2)
SGPT: 49 U/L (N. up to 65 )
SGOT: 31 U/L (N. up to 37 )

12. Laboratory Investigations:
Serum Uric acid : 4.0 mg/dl( normal 2-6 mg/l)
C – Reactive protein (CRP): 20 mg/l ( normal : 6 mg/l)
ESR: 60 - 97 mm/hr
Rheumatoid factor (Latex): Negative 8 ( normal : 16 units/l)

13. Laboratory Investigations:
ANA (ELISA) : Positive 45 ( normal 25 unit/ml )
ACPA (Anti CCP) : Negative 12 ( normal : 20 unit/ml )

14. Diagnosis
Sero-Negative
Rheumatoid
Arthritis

15. • Me t h o t r e x a t e
i n j e c t i o n
20 m g / w e e k S .C
• F o l i c a c i d 1 mg
o f
i n t h e f o r m
2 t a b l e t s
500 u g /d a y
• L e f l u n o m i d e 20m g
o n c e d a i l y o r a l l y
t a b l e t

17. 3 Month Later ….

19. Follow up visit
o Joint complain improved.
o She started complaining about her nails
and
asked
medications?
if
it
is
related
to
the

21. Her nails affection was suspected
as a psoriatic lesion.
She was referred to a Dermatologist.

23. Psoriatic Arthritis

25. Clinical presentations
of
Psoriatic skin lesions

26. Common sites affected by psoriasis
• Can affect any
part of the body
–
typically
scalp, elbow, kne
es and sacrum
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

27. Classic Psoriasis
o Well-defined and sharply
demarcated
o Round/oval-shaped
lesions
o Usually symmetrical
o Erythematous, raised
plaques
o Covered by white, silvery
scales
1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –
dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. Fast facts: psoriasis. 2nd ed.
Oxford: Health Press, 2004.

28. Types of psoriasis
• Chronic plaque
• Guttate
• Flexural
• Erythrodermic
• Pustular
o Localised and generalised
• Local forms
o Palmoplantar
o Scalp
o Nail (psoriatic
onychodystrophy)
1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed. Australian medicines
handbook. Adelaide: AMH, 2010.

29. Chronic plaque psoriasis
o Most
common
type
–
affects approximately 85%
o Features pink, well-defined
plaques with silvery scale
o Lesions may be single or
numerous
o Classically
elbows,
knees,
affects
buttocks
and scalp
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice
essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

30. Chronic plaque psoriasis

31. Chronic plaque psoriasis

32. Chronic plaque psoriasis

33. Guttate psoriasis
o Numerous and small
lesions – 1 cm diameter
o Pink with less scale than
plaque psoriasis
o Commonly found on
trunk and proximal limbs
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2.
Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice
essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al. J Am Acad Dermatol
2008; 58(5): 826–50.

34. Flexural psoriasis
o Lesions in skin folds
o Particularly
groin, gluteal
cleft, axillae and
submammary
regions.
o Often minimal or
absent scaling
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
2. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912.

35. Erythrodermic psoriasis
o Generalized erythema
covering entire skin
surface
o May evolve slowly from
chronic plaque psoriasis
or appear as eruptive
phenomenon
o Relatively uncommon
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2.
Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing
Company, 2005.
3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

36. Pustular psoriasis
o Two forms:
• Localized form
• More common
• multiple small pustules
on palms and soles
• Generalized form
• Uncommon
• widespread pustules
across inflamed body
surface
1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds. Rook’s
textbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

37. Palmoplantar psoriasis
o Can be
hyperkeratotic or
pustular
o Possibly aggravated
by trauma
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

38. Scalp psoriasis
o Varies from minor
scaling with erythema to
thick hyperkeratotic
plaques
o May extend beyond
hairline
o Patient scratching may
produce asymmetric
plaques
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

39. Nail psoriasis
o Can take several forms:
• Pitting: discrete, well-circumscribed depressions on nail surface.
• Subungual hyperkeratosis: silvery white crusting under free edge of nail
with some thickening of nail plate.
• Onycholysis: nail separates from nail bed at free edge.
• ‘Oil-drop sign’: pink/red color change on nail surface.

40. Nail psoriasis

41. Nail psoriasis

42. No need for a
Dermatologist then
?

43. You will always need
my knowledge & I will
prove it to you

44. Localised patches/plaques
Tinea corporis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Psoriasis

45. Localised patches/plaques
Discoid eczema
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Psoriasis

46. Localised patches/plaques
o Superficial basal cell
carcinoma/Bowen’s
disease
Bowen’s disease
Psoriasis
1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis.
2nd ed. Oxford: Health Press, 2004.

47. Localised patches/plaques
o Seborrhoeic dermatitis
Dermatitis
1. Marks R et al. Dermatology within the pharmacy. Australia: Department of
Dermatology, St Vincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis. 2nd ed.
Oxford: Health Press, 2004.
Psoriasis

48. Localised patches/plaques
Psoriasis
Mycosis fungoides
1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. Menter
A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

49. Want more ?

50. Guttate psoriasis
< Psoriasis
^ Pityriasis rosea
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press, 2004.
50

51. Guttate psoriasis
< Psoriasis
^ Secondary syphilis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis.
2nd ed. Melbourne: Blackwell Publishing, 2003.
51

52. Flexural psoriasis
< Psoriasis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor. 16 April 2010: 29–36.
^ Atopic eczema
52

53. Palmoplantar psoriasis
o Tinea manum
Tinea corporis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Psoriasis
53

54. Palmoplantar psoriasis
o Hand and foot eczema
Eczema
Psoriasis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press, 2004. 2. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed.
Melbourne: Blackwell Publishing, 2003.
54

57. Take Home Message