CASE STUDY

Case Courtesy Credit

Dr. Kiran Godse
Professor Dept. of Dermatology Venereology and Leprosy,
D. Y. Patil Medical College and Research Centre, Navi Mumbai
 ◾ Sex – F

◾ Age – 61 years

◾ Married, Homemaker

Patient ◾ Socioeconomic Status: Lower

Middle Class

Particulars ◾ From Nerul, Navi Mumbai,

Maharashtra
Chief complaints:

 Fluid filled lesions on inner sides of

thighs since 7 days followed with
fever
◾ Apparently well 7 days back, when

she developed high grade fever

◾ After which the lesions developed on the inner

side of the thighs and were initially pinhead

like in size but gradually progressed within 3
days

◾ H/O lesions progressing to involve palms as

well

History of Present Illness

Case For Discussion Purpose only Images copyrighted
 ◾ H/O mild pain over the lesions

◾ H/O similar lesions 7 years back

◾ H/O COVID-19 disease (7-17

May’22)

History

Case For Discussion Purpose only

 No
H/O :
◾ any photosensitivity, no outdoor activities or exacerbation
on sun exposure

Negative ◾ any drug intake prior to the onset of his skin

manifestations
◾ Any systemic disorder-----

History • Diabetes
• Hypertension
• Jaundice, Asthma or allergic rhinitis
• Thyroid disorders

◾ Any known drug or food allergy

Case For Discussion Purpose only

 ◾ Sleep – Normal, adequate

Personal ◾ Appetite : normal, unaltered

◾ Diet: Vegetarian
History ◾ Bowel, Bladder habits : unaltered
◾ No H/O any addiction or substance
abuse
◾ Menstruation: Menopause since
2009; Menarche 14 years of age
◾ Ob. History: G2P2L2AO; LSCS in

Family ◾ 1984
Married 35 years
◾ No family history of similar complaints/illness
or any other significant medical illnesses

Histor
Case For Discussion Purpose only
 • Prior incidence of similar lesions 7 years

back was treated with Oral medications,

Treatmen showed relief with the therapy

t • Details not available

History

Case For Discussion Purpose only

 ◾ Calm, Conscious, Co-operative
◾ Well Oriented in time, place and person;
Sitting comfortably
◾ Well built and nourished
General ◾ Weight – 76 Kg, Height - 160 cm
Examination ◾
◾ Temperature – Afebrile, normal to touch
Pulse – 72/min, Regular ; Respiratory rate –
13/ min
◾ BP- 120/86mmHg (left supine position)
◾ Pallor; Icterus, cyanosis – Absent
◾ Clubbing : Absent ; JVP: not raised
◾ No Bilateral pedal oedema or No
Case For Discussion Purpose only
lymphadenopathy
 ◾ CNS – WNL; conscious, well oriented
◾ CVS – S1, S2 + , no murmur
◾ Respiratory System – AEBE, Bilateral vesicular BS,

Systemic no added sounds; chest expansion WNL

◾ Per abdomen – soft, non-tender, no

Examination organomegaly, Bowel sounds +

◾ Musculoskeletal system – Power normal across
all joints; No joint swelling, tenderness, crepitus
or deformity; range of motion of joints WNL

Case for Discussion Purpose only

 Multiple well-defined white pustules on an erythematous
base with few large erosions over bilateral lower limbs and
right hand

Case for discussion Purpose only

Cutaneous Examination Images copyrighted
 Two fluid-producing bullae over left calf

Cutaneous Examination
Case for discussion Purpose only Images copyrighted
 Cutaneous Examination

Epidermal sloughing present; Tenderness present

+ Local rise of temperature+
Case for discussion Purpose only
 ◾ Hair and Scalp- NAD
Cutaneous ◾ Genitals and oral mucosa:
Examination Normal

For Discussion Purpose only

 ◾ 61-year-old homemaker, fluid-filled lesions on inner
sides of thighs since 7 days preceded by high grade
fever 7 days back The lesions were initially pinhead
in size and gradually increased within 3 days with
progression of lesions to the palms. The lesions were
associated with mild pain and rupturing.
◾ Had similar lesions in the past 7 years ago but
Summary past medical, personal history was normal.
◾ General and systemic examinations were grossly
normal
◾ Cutaneous examination revealed multiple well defined
white pustules on an erythematous base with few large
with epidermal sloughing and associated with local
rise of temperature and tenderness; no involvement of
Case For Discussion Purpose only
oral cavity, scalp and genitals
 ◾ Acute generalized exanthematous
pustulosis

◾ Pustular psoriasis

◾ Drug eruption reaction

Differentia ◾ Pemphigus vulgaris/ foliaceous

l ◾ Dermatitis Herpetiformis

Diagnoses ◾ Erythroderma

◾ Acute cutaneous lupus

◾ Disseminated herpes simplex

virus
Shah M, Al Aboud DM, Crane JS, et al. Pustular Psoriasis. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537002/ For Discussion Purpose only
 Pustular
Psoriasis

Final Diagnosis
 Approach to this patient….
General Management:

 Encourage fluid and protein intake

 Monitor input/output

 Treat infection, if any, with antibiotic

 Prevent hypothermia

For Discussion Purpose only

 Approach to this patient….
Specific Management:

Topical
• Bland emollients
• Corticosteroids

Systemic
• Acitretin (not given in pregnancy)
• Cyclosporine
• Methotrexate
• Infliximab
• Adalimumab
• Etanercept
• Prednisolone (only in special conditions, e.g., complications)
• Anakinra

For Discussion Purpose only

 Discussi
on
Pointers
For Discussion Purpose only
 Discussion Pointers
 What are the different variants or subtypes of pustular
psoriasis?

 What is impetigo herpetiformis?

 Which drugs cause this type of drug reaction?

 How will you evaluate this patient?

 What are the histopathological features of pustular psoriasis?

 What are the complications of pustular psoriasis?

Document Code: PM-IN-COP-PPTX-220008 DoP: August 2022
For the Use of Registered Medical Practitioner or Hospital or Laboratory Only.

“Registered medical practitioners can refer company website

http://india-pharma.gsk.com/en-in/products/prescribing-information/ for full Product Information.
Please report adverse events with any GSK product to the company at india.pharmacovigilance@gsk.com
GlaxoSmithKline Pharmaceuticals Ltd, Dr Annie Besant Road, Worli, Mumbai-30