A 50 year old male cattle herdsman with no known personal or family history of skin disorders presented for evaluation of skin eruptions which had been evolving for about 2 years prior consultation. Patient was living in the forest at the onset of these lesions and noticed they were painless, pruritic and scaly eruptions which developed on his scalp, face and both upper extremities. Initial thought was a supposed fungal infection for which he took both topical and systemic terbinafine (taken liberally as an over the counter drug) for an unknown duration to no benefit. Progress was characterized by worsening of the lesions, with increased size of eruptions, thickening of underlying skin and further involvement of the entire trunk. However, the lower limbs, palms and soles were unaffected. About two weeks prior consultation to our service, he developed red itchy eyes, generalized polyarthralgia, frequent chills and diminished interest in almost all daily activities. He denied previous history of tuberculosis, alcohol consumption and exposure to toxic chemicals. On physical examination, the patient looked well and comfortable with vital signs within normal limits. He had corneal and conjunctival hyperemia with no sign of oedema or cicatricial ectropion. There were well-defined inflammatory plaques covering about 61% of his total body surface area (TBSA) with associated scaling, lichenification and accentuated skin markings (Figure 1). Superficial exfoliation of the face was noted and the lesions were discrete, firm, and silver grey, involving the entire integument but for the lower limbs, palms and soles (Figure 2A).
Nail examination revealed no area of dystrophy or pitting. Examination of the cardiovascular and respiratory systems revealed no abnormality likewise joint examination for any tenderness or edema. Blood and tissue cultures were negative for bacteria, fungi and atypical mycobacteria. Serological tests for HIV and Syphilis were also negative likewise skin snip for filaria. His baseline lipid profile was normal so too was work up for Hepatitis B and C. Punch biopsy of skin was consistent with psoriasis and focal suppurative folliculitis (Microscopic Description: Sections reveal skin with acanthosis, elongated retia, hyperkeratosis with parakeratosis, focal neutrophilic infiltration of the epidermis, loss of granular layer, focal spongiosis and suprapapillary thinning. One fragment showed a suppurative folliculitis with dermal abscess. Dermis with inflammatory infiltrates that include neutrophils is seen in other areas. PAS and Gram stain failed to recover fungal and bacterial organisms). The diagnosis of severe chronic plaque type psoriasis was made based on his psoriasis severity index (PASI) score of 13.6 (> 12) and a BSA 61% (> 10%) (Table 1). Owing to our low income resource, a topical steroid (Betamethasone 0.05% topical), topical moisturizer (petroleum jelly), systemic therapy (methotrexate: 10mg weekly initially) and daily sun exposure were the treatment modalities employed. Fluorometholone Acetate was also added to aid with the ocular inflammation whilst psychiatric evaluation was sort. Patient was however lost to follow up and was seen about 8 months later with complete resolution of plaques following the repeated ingestion of some unknown homemade indigenous medications (Figure 2B) PASI 3.8, which he took in preference to medical treatment.