Abstract

Palmoplantar psoriasis is an infrequent variant of psoriasis which has been associated with varied clinical presentations. It is historically difficult to treat and is known for its significant burden on the patient’s daily life activities. This case describes a patient with palmoplantar psoriasis whose symptoms did not improve on optimal topical treatment in primary care, leading to the suspicion of a common differential diagnosis of psoriasis.

Keywords: Palmoplantar psoriasis; Tinea pedis; Hyperkeratotic tinea; Topical corticosteroids; Antifungal agents.

Citation: Carnide S, Lopes PL, Alves JF. Hyperkeratotic plaques - Beyond psoriasis. J Clin Images Med Case Rep. 2024; 5(12): 3407.

Description

A 33-year-old woman with a previous diagnosis of Palmo-Plantar Psoriasis (PPP) was observed by her family doctor for pain, pruritus and discomfort on the soles of both feet, despite daily application of an emollient cream and a potent corticosteroid and calcipotriol ointment for 12 weeks. She is a fishmonger and wears occlusive footwear everyday. Physical examination revealed erythema and hyperkeratotic plaques on the forefoot, toes and calcaneus bilaterally, associated with thick yellow scales, fissures and intertriginous maceration (Figure 1). Given the occupational risk factors and persistence of the lesions with optimized topical treatment for PPP, a presumptive diagnosis of hyperkeratotic (moccasin-type) tinea pedis was made. The patient was started on a combination treatment of oral terbinafine (250 mg qd) and a topical antifungal agent, as well as a keratolytic ointment with 30% urea, for four weeks, with complete resolution of her symptoms.

Discussion

Superficial fungal infections are an important differential diagnosis of psoriasis [1,2]. A careful observation and consider ation of the patient’s risk factors were paramount in the differ- ential diagnosis of the hyperkeratotic plaques. Hyperkeratotic tinea pedis is usually difficult to treat. Oral antifungals are often needed and combination with topical antifungals may increase cure rates [2] as well as improve compliance with the treatment [3].

Declarations

Authors contributions

SC: Data acquisition, literature search, conception of the work, writing and critical review of the manuscript.

PLL: Data acquisition, literature search, conception of the work and critical review of the manuscript.

JFA: Conception of the work and critical review of the manuscript.

All authors approved the final version to be published.

Conflict of interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Figure 1: Initial presentation of hyperkeratotic (moccasin-type) tinea pedis on a patient with palmoplantar psoriasis.

References

1. Burhan E, Aşkın O, Tüzün Y. Palmoplantar Psoriasis. 2017; 35: 19-27.
2. Leung AKC, Barankin B, Lam JM, Leon KF, Hon KL. Tinea pedis: an updated review. Drugs Context. 2023; 12: 2023-5-1.
3. Shi T, Zhang J, Zhang X, Yu H, Tang Y, et al. Combination treatment of oral terbinafine with topical terbinafine and 10% urea ointment in hyperkeratotic type tinea pedis. 2014; 57: 560-4.