A 68-year-old female attended to our outpatient clinic with a 2-month history of persistent, rapidly developing and aching ulcers affecting her feet (Figure 1Ai-Aiii) and 1-year history of plaque psoriatic lesions symmetrically distributed on the lower extremities (Figure 1Bi-Biii). Pustules were found on her palms (Figure 1Ci). She denied history of lesions on her face and joint symptoms.
Laboratory investigations revealed elevated levels of C-reactive protein (14.1 mg/L; normal, <8 mg/L) and erythrocyte sedimentation rate (74 mm/H; normal, <20 mm/H). The outcome of syphilis antibody and T cell spot test for tuberculosis infection was negative. We have scraped some flakes for fungal culture to rule out fungal infections. Other laboratory investigations, including complete blood count, liver functions and renal functions were unremarkable. Histopathology of the ulcer near the right medial malleolus showed dense neutrophils which confined to the dermis (Figure 2), with no indication of cutaneous vasculitis, mycobacterium tuberculosis, parasitic infections or fungal infections. The clinical and histopathological findings above were consistent with PG. Based on the erythematous scaly plaques distributed on the lower extremities, diagnosis of plaque psoriasis was made. The patient also had pustules on her palms leading to the clinical diagnosis of PPP.
She was treated with adalimumab with 80 mg subcutaneously at week 0 and then 40 mg every 2 weeks. In the third month, the lesions of PG (Figure 1Aiv-Avi), psoriasis (Figure 1Biv-Bvi) and PPP (Figure 1Cii) improved markedly. The Psoriasis Area Severity Index score improved from 2.4 to 0.2. The body surface area of psoriasis reduced from 1.5% to 0.5%. She did not report any adverse effects during the period of therapy.