An 18-year-old male came to our hospital with a generalized hyperkeratotic lesion associated with pruritus for 12 months, which was exaggerated for 4 months. Physical examination revealed generalized firmly demarcated erythematous circular plaques covered with thick adherent greasy yellowish scales resembling oyster shells over his scalp, face, trunk, upper and lower extremities, groin, and buttocks (Figure 1A and B). The baseline psoriasis activity severity index (PASI) and body surface area (BSA) scores were 22.8% and 14% respectively. The patient had a history of bipolar disorder for 1.5 years for which he was taking LC. After the dose of LC increased, his condition significantly deteriorated. He denied any infectious disease or arthritis. The patient was treated in the local hospital for neurodermatitis, for which topical steroids were given with no improvement.
Tuberculosis, HIV, hepatitis, syphilis and other related laboratory screenings showed no obvious abnormalities, except for elevation of C-reactive protein levels (12.00 mg/L). Histopathology revealed psoriasiform hyperplasia of the epidermis with confluent parakeratosis, neutrophils infiltration in the stratum corneum, and a moderate amount of lymphocytes around small vessels in the superficial dermis (Figure 2).
The patient was started on adalimumab subcutaneous injection of 80 mg initial dose then 40 mg every 2 weeks. On the 9-week follow-up, a small improvement was seen. With his history of taking LC, which can exacerbate psoriasis, we advised him to stop taking it under the guidance of a psychiatrist. He gradually stopped taking LC and switched to olanzapine tablets and magnesium valproate after consulting a psychiatrist. After 18 weeks of treatment and stopping of LC, there was a marked improvement (Figure 3A and B). On reassessment, his PASI and BSA scores were 0.3% and 0.5%, respectively.