Porokeratosis Concurrent and Coexistent with Psoriasis Vulgaris

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North American Journal of Medicine and Science

American Chinese Medical Exchange Society

Acmes Publications Inc

Subject: Medicine

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ISSN: 1946-9357
eISSN: 2156-2342

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Volume 10 (2017)

VOLUME 10 , ISSUE 2 (April 2017) > List of articles

Porokeratosis Concurrent and Coexistent with Psoriasis Vulgaris

Melissa M. Helm * / Robert E. Kalb / Mazin Dhafir

Keywords : porokeratosis, psoriasis, cornoid lamella, phototherapy, gene profiling

Citation Information : North American Journal of Medicine and Science. VOLUME 10 , ISSUE 2 , ISSN (Online) 2156-2342, DOI: 10.7156/najms.2017.1002070, April 2017 © 2017.

License : (Transfer of Copyright)

Received Date : 30-January-2017 / Accepted: 17-April-2017 / Published Online: 25-May-2017

ARTICLE

ABSTRACT

Disseminated superficial actinic porokeratosis is a rare photodistributed disorder that has occasionally been reported in association with psoriasis. Treatment of psoriasis with phototherapy may trigger the onset of porokeratosis in some cases. In other cases, the coexistence of these disorders may be coincidental. Clinical inspection of lesions of coexisting porokeratosis and psoriasis reveals increased erythema, diffuse and thickening of cornoid lamellae, as well as increased scale. These subtle yet characteristic features allow for correct clinical diagnosis and are associated with corollary histologic findings. Psoriatic changes occurring in lesions of porokeratosis are likely explained by the isomorphic (Koebner) response. Physicians should be aware that these two disorders can co-exist in order to ensure correct diagnosis and proper treatment.

Graphical ABSTRACT

Introduction

Psoriasis vulgaris affects about 3% of the adult US population.1 Porokeratosis represents a clonal proliferation of keratinocytes that is usually progressive unless treated. Lesions may be associated with the development of squamous cell carcinoma. Superficial actinic porokeratosis is associated with actinic damage. Phototherapy given to treat psoriasis can be associated with resultant disseminated superficial actinic porokeratosis.2 Both psoriasis and porokeratosis are known to have a genetic component. Recent research has identified specific genes associated with some of the autosomal dominant forms of porokeratosis.3 Porokeratosis also seems to be able to trigger an isomorphic response with psoriasis vulgaris. Immunomodulating medications have been associated with the onset of porokeratosis and discontinuation of immunosuppressive treatment has been associated with improvement.4,5,6 We report the illustrative case of a patient who demonstrated lesions with features of both psoriasis vulgaris and porokeratosis.

Clinical Case

A 63-year-old man presented for evaluation of a widespread skin eruption. He had a history of psoriasis treated with narrow band ultraviolet B phototherapy (UVB) and oral acitretin. His topical regimen consisted of intermittent application of clobetasol propionate foam (0.05%) and triamcinolone 0.1% cream. He also applied a generic hand sanitizer containing isopropyl alcohol and felt that this worked better than the prescription corticosteroid products.

Physical examination revealed a widespread inflammatory eruption consisting of erythematous papules and plaques. Symmetric scaling plaques were noted on the elbows and extensor surfaces along with annular lesions (Figure 1). Many annular lesions were associated with surrounding erythema (Figures 2 and Figure 3). Review of a biopy from the left upper thigh (Figures 4 and Figure 5) revealed dyskeratotic keratinocytes and cornoid lamellae as well as collections of neutrophils and early spongiform pustule formation. The histologic changes supported the clinical impression of disseminated superficial actinic porokeratosis associated with psoriasis. He was treated with a lotion consisting of 12% lactic acid neutralized with ammonium hydroxide (ammonium lactate) and a keratolytic emollient cream with 40% urea. His itching improved but the lesions persisted.

Figure 1.

Typical psoriasis is evident in the hick plaques with silvery scale over the knees. Smaller annular erythematous scaling lesions are noted on the thighs and legs.

10.7156_najms.2017.1002070-f001.jpg
Figure 2.

Many erythematous lesions on the left lower leg reveal a well-defined scaling border.

10.7156_najms.2017.1002070-f002.jpg
Figure 3.

Close up of the right ankle reveals that the cornoid lamella of many lesions is discontinuous, there is more erythema than typically encountered in the setting of disseminated superficial actinic porokeratosis, and flakes of scale are irregular is size rather than coalescing in a focused narrow hyperkeratotic rim.

10.7156_najms.2017.1002070-f003.jpg
Figure 4.

Biopsy reveals a typical cornoid lamella angled in towards the center of the clinical lesion. (Hematoxylin and eosin stained sections; original magnification 200x).

10.7156_najms.2017.1002070-f004.jpg
Figure 5.

Not only are dyskeratotic keratinocytes noted, small collections of neutrophils are evident in areas overlying dyskeratotic keratinocytes. The granular cell layer is lost in this area, showing features of both psoriasis and porokeratosis. (Hematoxylin and eosin stained sections; original magnification 400x).

10.7156_najms.2017.1002070-f005.jpg

Discussion

Psoriasis is common and may have many different presentations. Porokeratosis is relatively rare and can be mistaken for psoriasis.7 The Koebner phenomenon has been suspected of contributing to this interesting finding.8 Psoriasis has been reported to be occurring “on top of the porokeratosis lesions” as in our case.8 Careful review of his clinical lesions revealed increased erythema and blunting of the keratotic annulus characteristic of disseminated superficial actinic porokeratosis. Dermoscopy of psoriasis reveals dotted vessels distributed over a pink background in a regular fashion and associated with superficial white scale.9 Porokeratosis is associated with a more discrete white rim associated with dotted and irregular blood vessels.9 The more diffuse rim and more pronounced surrounding erythema in our case help differentiate the findings in our patient from a patient with typical disseminated superficial actinic porokeratosis. Psoriasis is associated with certain genetic abnormalities.10 Porokeratosis and psoriasis share certain gene profiles. Study of K16, S-100, A8 and A9, and connexin26 gene upregulation demonstrates closer similarities between psoriasis and porokeratosis than squamous cell carcinoma.11 These results suggest that similarities between porokeratosis and psoriasis could be of use in devising successful therapeutic strategies.11 Failure to identify superficial actinic porokeratosis occurring in conjunction with psoriasis may lead to additional phototherapy treatment that could worsen disease.12 Recognizing the subtle clues for diagnosis can allow for appropriate treatment and a better understanding of both these interesting disorders.

References


  1. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70:512.
    [CROSSREF]
  2. Hazen PG, Carney JF, Walker AE, Stewart JJ, Engstrom CW. Disseminated superficial actinic porokeratosis: appearance associated with photochemotherapy for psoriasis. J Am Acad Dermatol. 1985;12:1077-1078.
    [CROSSREF]
  3. Luan J, Niu Z, Zhang J et al. A novel locus for disseminated superficial actinic porokeratosis maps to chromosome 16q24.1-24.3 Hum Genet. 2011;129:329.
    [CROSSREF]
  4. Stewart L, Howat A, Coulson I. Disseminated superficial porokeratosis secondary to immunosuppression induced by etanercept for extensive psoriasis. Arch Dermatol. 2010;146: 1193-1194.
  5. Jung JY, Yeon JH, Ruy HS, Youn SW, Park KC, Huh CH. Disseminated superficial porokeratosis developed by immunosuppression due to rheumatoid arthritis treatment. J Dermatol. 2009;36:466-467.
    [CROSSREF]
  6. Tsambaos D, Spiliopoulos T. Disseminated superficial porokeratosis: complete remission subsequent to discontinuation of immunosuppression. J Am Acad Dermatol. 1993;28:651-652.
    [CROSSREF]
  7. De Simone C, Paradisi A, Massi G, et al. Giant verrucous porokeratosis of Mibelli mimicking psoriasis in a patient with psoriasis. J Am Acad Dermatol. 2007;57:665-668.
    [CROSSREF]
  8. Matsui Y, Mochizuki T, Yanagihara M, Ishizaki H. A case of porokeratosis associated with psoriasis vulgaris. Hifu. 1998;40:365-368.
  9. Moscarella E, Longo C, Zalaudek I, Argenziano G, Piana S, Lallas A. Dermoscopy and confocal microscopy clues in the diagnosis of psoriasis and porokeratosis. J Am Acad Dermatol. 2013;69:e231-233.
    [CROSSREF]
  10. Ryan C, Korman NJ, Gelfand JM, et al. Research gaps in psoriasis: opportunities for future studies. J Am Acad Dermatol. 2014;70:146-167.
    [CROSSREF]
  11. Hivnor C, Williams N, Singh F, et al. Gene expression profiling of porokeratosis demonstrates similarities with psoriasis. J Cutan Pathol. 2004;31:657-64.
    [CROSSREF]
  12. Cockerell CJ. Induction of disseminated superficial actinic porokeratosis by phototherapy for psoriasis. J Am Acad Dermatol. 1991;24:301-302.
    [CROSSREF]
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FIGURES & TABLES

Figure 1.

Typical psoriasis is evident in the hick plaques with silvery scale over the knees. Smaller annular erythematous scaling lesions are noted on the thighs and legs.

Full Size   |   Slide (.pptx)

Figure 2.

Many erythematous lesions on the left lower leg reveal a well-defined scaling border.

Full Size   |   Slide (.pptx)

Figure 3.

Close up of the right ankle reveals that the cornoid lamella of many lesions is discontinuous, there is more erythema than typically encountered in the setting of disseminated superficial actinic porokeratosis, and flakes of scale are irregular is size rather than coalescing in a focused narrow hyperkeratotic rim.

Full Size   |   Slide (.pptx)

Figure 4.

Biopsy reveals a typical cornoid lamella angled in towards the center of the clinical lesion. (Hematoxylin and eosin stained sections; original magnification 200x).

Full Size   |   Slide (.pptx)

Figure 5.

Not only are dyskeratotic keratinocytes noted, small collections of neutrophils are evident in areas overlying dyskeratotic keratinocytes. The granular cell layer is lost in this area, showing features of both psoriasis and porokeratosis. (Hematoxylin and eosin stained sections; original magnification 400x).

Full Size   |   Slide (.pptx)

REFERENCES

  1. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70:512.
    [CROSSREF]
  2. Hazen PG, Carney JF, Walker AE, Stewart JJ, Engstrom CW. Disseminated superficial actinic porokeratosis: appearance associated with photochemotherapy for psoriasis. J Am Acad Dermatol. 1985;12:1077-1078.
    [CROSSREF]
  3. Luan J, Niu Z, Zhang J et al. A novel locus for disseminated superficial actinic porokeratosis maps to chromosome 16q24.1-24.3 Hum Genet. 2011;129:329.
    [CROSSREF]
  4. Stewart L, Howat A, Coulson I. Disseminated superficial porokeratosis secondary to immunosuppression induced by etanercept for extensive psoriasis. Arch Dermatol. 2010;146: 1193-1194.
  5. Jung JY, Yeon JH, Ruy HS, Youn SW, Park KC, Huh CH. Disseminated superficial porokeratosis developed by immunosuppression due to rheumatoid arthritis treatment. J Dermatol. 2009;36:466-467.
    [CROSSREF]
  6. Tsambaos D, Spiliopoulos T. Disseminated superficial porokeratosis: complete remission subsequent to discontinuation of immunosuppression. J Am Acad Dermatol. 1993;28:651-652.
    [CROSSREF]
  7. De Simone C, Paradisi A, Massi G, et al. Giant verrucous porokeratosis of Mibelli mimicking psoriasis in a patient with psoriasis. J Am Acad Dermatol. 2007;57:665-668.
    [CROSSREF]
  8. Matsui Y, Mochizuki T, Yanagihara M, Ishizaki H. A case of porokeratosis associated with psoriasis vulgaris. Hifu. 1998;40:365-368.
  9. Moscarella E, Longo C, Zalaudek I, Argenziano G, Piana S, Lallas A. Dermoscopy and confocal microscopy clues in the diagnosis of psoriasis and porokeratosis. J Am Acad Dermatol. 2013;69:e231-233.
    [CROSSREF]
  10. Ryan C, Korman NJ, Gelfand JM, et al. Research gaps in psoriasis: opportunities for future studies. J Am Acad Dermatol. 2014;70:146-167.
    [CROSSREF]
  11. Hivnor C, Williams N, Singh F, et al. Gene expression profiling of porokeratosis demonstrates similarities with psoriasis. J Cutan Pathol. 2004;31:657-64.
    [CROSSREF]
  12. Cockerell CJ. Induction of disseminated superficial actinic porokeratosis by phototherapy for psoriasis. J Am Acad Dermatol. 1991;24:301-302.
    [CROSSREF]

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