A 48-year-old African American woman with a history of bipolar disorder on aripripazole and bupropion and hypertension presented to the emergency department with signs of dehydration and sepsis. In addition, the patient described acute worsening of a chronic skin condition. The patient was unable to bear weight due to pain in her lower extremities.
On examination, the patient was completely covered in thick adherent hyperkeratotic malodorous plaques on her scalp, face, trunk, arms, and legs (Figures 1-3). In the few areas of skin not covered by keratotic plaques, erythema was noted. Her nails were also thick and hyperkeratotic with extensive subungual debris. Ocular exam was significant for purulent yellow drainage from both eyes. The patient reported a 20-plus year history of psoriasis.
Laboratory findings were notable for a mild leukocytosis with a white blood cell count of 12.5 × 103/uL (reference range 4.8-10.8 × 103/uL) and elevated C-reactive protein of 12.9 mg/L (reference range <3.0 mg/L). HIV antibodies and hepatitis panel were negative. Radiologic studies of the hands, hips, ankles, and sacroiliac joint did not demonstrate erosive arthritis.
Discussion
The term rupioid or rupio, derived from the Greek word rhupo which means either dirt or filth, is used to describe lesions that resemble syphilitic rupia. These lesions are characterized by dark, well-demarcated hyperkeratotic plaques that commonly present as circular lesions with concentric layers that resemble a cone or a limpet-like shell.1
The plaques associated with rupioid psoriasis are distinguished from those of other uncommon psoriasis variants based on shape, thickness, and color. Ostraceous psoriasis is distinguished by more circular or oval-shaped lesions that resemble an oyster shell and may have a characteristic concave center.2 Elephantine psoriasis is characterized by silver or white scaling plaques that cover large areas of the body. These lesions are found predominantly on the back and limbs.3 While there is a distinction made between rupioid and ostraceous psoriasis, review of the literature reveals these terms have been used interchangeably. It is also apparent that similar descriptions have been used to describe the plaques of both variants. These overlapping descriptions are not surprising considering both variants existed under the same term of psoriasis exudative until the 1960s.2
Differential Diagnosis
When presented with cutaneous plaques of this nature, several other conditions with similar presentations should be considered. The differential diagnosis includes secondary syphilis, crusted scabies, and other rare types of psoriasis. Crusted scabies can present with lesions similar to that of rupioid psoriasis; however, it is predominantly seen in immunocompromised individuals or those with psychiatric disorders. Due to the extremely high mite burden in the skin, a skin biopsy can easily discriminate between psoriasis and crusted scabies.4 Secondary syphilis can be assessed using lab serologies such as a rapid plasma reagin test or looking for evidence of plasma cells on skin biopsy.1 The patient in this case had recently undergone several skin biopsies at an outside institution that were consistent with psoriasis.
Treatment
Given the extent of the patient’s skin disease, systemic treatment with cyclosporine or a biologic agent was recommended. However, the patient declined systemic therapy due to the associated risks of these medications, including potential risk of infection and malignancy.
The only treatment that the patient was amenable to was topical therapy with triamcinolone acetonide 0.1% ointment, applied twice daily under occlusion using wet wraps. After 5 days of wet wrap therapy, significant improvement of the skin with desquamation of the adherent plaques on all sites of the body were noted. Although topical treatment is typically not effective in cases of rupioid psoriasis due to the thickness of the plaques, lack of patient compliance to an intensive topical treatment regimen may impact its historical ineffectiveness.5
The patient continued to improve with topical treatments over the next several weeks as she remained in the inpatient setting (Figure 4). The patient was eventually discharged to a skilled nursing facility due to overall deconditioning from her inpatient hospital stay.
Ms Papier is with Wake Forest University School of Medicine, department of dermatology, in Winston Salem, NC.
Dr Ahn is with Wake Forest University School of Medicine, department of dermatology, in Winston Salem, NC.
Dr Strowd is assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Disclosure: The authors report no relevant financial relationships.
References
1. Chung HJ, Marley-Kemp D, Keller M. Rupioid psoriasis and other skin diseases with rupioid manifestations. Cutis. 2014;94(3):119-121.
2. Salamon M, Omulecki A, Sysa-Jedrzeejowska A, McCauliffe DP, Wozniacka A. Psoriasis rupioides: a rare variant of a common disease. Cutis. 2011;88(3):135-137.
3. Koley S, Mandal RK, Chatterjee K, Hassan SM, Pathak S. Elephantine psoriasis with papillomatosis and alternating hypogranulosis and hypergranulosis. Indian J Dermatol. 2015;60(3):264-267.
4. Costa JB, Rocha de Sousa VL, da Trindade Neto PB, Paulo Filho, Tde A , Cabral VC, Pinheiro PM. Norwegian scabies mimicking rupioid psoriasis. An Bras Dermatol. 2012;87(60):910-913.
5. Feldman SR, Brown KL, Heald P. ‘Coral reef’ psoriasis: a marker of resistance to topical treatment. J Dermatolog Treat. 2008;19(5):257-258.
A 48-year-old African American woman with a history of bipolar disorder on aripripazole and bupropion and hypertension presented to the emergency department with signs of dehydration and sepsis. In addition, the patient described acute worsening of a chronic skin condition. The patient was unable to bear weight due to pain in her lower extremities.
On examination, the patient was completely covered in thick adherent hyperkeratotic malodorous plaques on her scalp, face, trunk, arms, and legs (Figures 1-3). In the few areas of skin not covered by keratotic plaques, erythema was noted. Her nails were also thick and hyperkeratotic with extensive subungual debris. Ocular exam was significant for purulent yellow drainage from both eyes. The patient reported a 20-plus year history of psoriasis.
Laboratory findings were notable for a mild leukocytosis with a white blood cell count of 12.5 × 103/uL (reference range 4.8-10.8 × 103/uL) and elevated C-reactive protein of 12.9 mg/L (reference range <3.0 mg/L). HIV antibodies and hepatitis panel were negative. Radiologic studies of the hands, hips, ankles, and sacroiliac joint did not demonstrate erosive arthritis.
Discussion
The term rupioid or rupio, derived from the Greek word rhupo which means either dirt or filth, is used to describe lesions that resemble syphilitic rupia. These lesions are characterized by dark, well-demarcated hyperkeratotic plaques that commonly present as circular lesions with concentric layers that resemble a cone or a limpet-like shell.1
The plaques associated with rupioid psoriasis are distinguished from those of other uncommon psoriasis variants based on shape, thickness, and color. Ostraceous psoriasis is distinguished by more circular or oval-shaped lesions that resemble an oyster shell and may have a characteristic concave center.2 Elephantine psoriasis is characterized by silver or white scaling plaques that cover large areas of the body. These lesions are found predominantly on the back and limbs.3 While there is a distinction made between rupioid and ostraceous psoriasis, review of the literature reveals these terms have been used interchangeably. It is also apparent that similar descriptions have been used to describe the plaques of both variants. These overlapping descriptions are not surprising considering both variants existed under the same term of psoriasis exudative until the 1960s.2
Differential Diagnosis
When presented with cutaneous plaques of this nature, several other conditions with similar presentations should be considered. The differential diagnosis includes secondary syphilis, crusted scabies, and other rare types of psoriasis. Crusted scabies can present with lesions similar to that of rupioid psoriasis; however, it is predominantly seen in immunocompromised individuals or those with psychiatric disorders. Due to the extremely high mite burden in the skin, a skin biopsy can easily discriminate between psoriasis and crusted scabies.4 Secondary syphilis can be assessed using lab serologies such as a rapid plasma reagin test or looking for evidence of plasma cells on skin biopsy.1 The patient in this case had recently undergone several skin biopsies at an outside institution that were consistent with psoriasis.
Treatment
Given the extent of the patient’s skin disease, systemic treatment with cyclosporine or a biologic agent was recommended. However, the patient declined systemic therapy due to the associated risks of these medications, including potential risk of infection and malignancy.
The only treatment that the patient was amenable to was topical therapy with triamcinolone acetonide 0.1% ointment, applied twice daily under occlusion using wet wraps. After 5 days of wet wrap therapy, significant improvement of the skin with desquamation of the adherent plaques on all sites of the body were noted. Although topical treatment is typically not effective in cases of rupioid psoriasis due to the thickness of the plaques, lack of patient compliance to an intensive topical treatment regimen may impact its historical ineffectiveness.5
The patient continued to improve with topical treatments over the next several weeks as she remained in the inpatient setting (Figure 4). The patient was eventually discharged to a skilled nursing facility due to overall deconditioning from her inpatient hospital stay.
Ms Papier is with Wake Forest University School of Medicine, department of dermatology, in Winston Salem, NC.
Dr Ahn is with Wake Forest University School of Medicine, department of dermatology, in Winston Salem, NC.
Dr Strowd is assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Disclosure: The authors report no relevant financial relationships.
References
1. Chung HJ, Marley-Kemp D, Keller M. Rupioid psoriasis and other skin diseases with rupioid manifestations. Cutis. 2014;94(3):119-121.
2. Salamon M, Omulecki A, Sysa-Jedrzeejowska A, McCauliffe DP, Wozniacka A. Psoriasis rupioides: a rare variant of a common disease. Cutis. 2011;88(3):135-137.
3. Koley S, Mandal RK, Chatterjee K, Hassan SM, Pathak S. Elephantine psoriasis with papillomatosis and alternating hypogranulosis and hypergranulosis. Indian J Dermatol. 2015;60(3):264-267.
4. Costa JB, Rocha de Sousa VL, da Trindade Neto PB, Paulo Filho, Tde A , Cabral VC, Pinheiro PM. Norwegian scabies mimicking rupioid psoriasis. An Bras Dermatol. 2012;87(60):910-913.
5. Feldman SR, Brown KL, Heald P. ‘Coral reef’ psoriasis: a marker of resistance to topical treatment. J Dermatolog Treat. 2008;19(5):257-258.
A 48-year-old African American woman with a history of bipolar disorder on aripripazole and bupropion and hypertension presented to the emergency department with signs of dehydration and sepsis. In addition, the patient described acute worsening of a chronic skin condition. The patient was unable to bear weight due to pain in her lower extremities.
On examination, the patient was completely covered in thick adherent hyperkeratotic malodorous plaques on her scalp, face, trunk, arms, and legs (Figures 1-3). In the few areas of skin not covered by keratotic plaques, erythema was noted. Her nails were also thick and hyperkeratotic with extensive subungual debris. Ocular exam was significant for purulent yellow drainage from both eyes. The patient reported a 20-plus year history of psoriasis.
Laboratory findings were notable for a mild leukocytosis with a white blood cell count of 12.5 × 103/uL (reference range 4.8-10.8 × 103/uL) and elevated C-reactive protein of 12.9 mg/L (reference range <3.0 mg/L). HIV antibodies and hepatitis panel were negative. Radiologic studies of the hands, hips, ankles, and sacroiliac joint did not demonstrate erosive arthritis.
Discussion
The term rupioid or rupio, derived from the Greek word rhupo which means either dirt or filth, is used to describe lesions that resemble syphilitic rupia. These lesions are characterized by dark, well-demarcated hyperkeratotic plaques that commonly present as circular lesions with concentric layers that resemble a cone or a limpet-like shell.1
The plaques associated with rupioid psoriasis are distinguished from those of other uncommon psoriasis variants based on shape, thickness, and color. Ostraceous psoriasis is distinguished by more circular or oval-shaped lesions that resemble an oyster shell and may have a characteristic concave center.2 Elephantine psoriasis is characterized by silver or white scaling plaques that cover large areas of the body. These lesions are found predominantly on the back and limbs.3 While there is a distinction made between rupioid and ostraceous psoriasis, review of the literature reveals these terms have been used interchangeably. It is also apparent that similar descriptions have been used to describe the plaques of both variants. These overlapping descriptions are not surprising considering both variants existed under the same term of psoriasis exudative until the 1960s.2
Differential Diagnosis
When presented with cutaneous plaques of this nature, several other conditions with similar presentations should be considered. The differential diagnosis includes secondary syphilis, crusted scabies, and other rare types of psoriasis. Crusted scabies can present with lesions similar to that of rupioid psoriasis; however, it is predominantly seen in immunocompromised individuals or those with psychiatric disorders. Due to the extremely high mite burden in the skin, a skin biopsy can easily discriminate between psoriasis and crusted scabies.4 Secondary syphilis can be assessed using lab serologies such as a rapid plasma reagin test or looking for evidence of plasma cells on skin biopsy.1 The patient in this case had recently undergone several skin biopsies at an outside institution that were consistent with psoriasis.
Treatment
Given the extent of the patient’s skin disease, systemic treatment with cyclosporine or a biologic agent was recommended. However, the patient declined systemic therapy due to the associated risks of these medications, including potential risk of infection and malignancy.
The only treatment that the patient was amenable to was topical therapy with triamcinolone acetonide 0.1% ointment, applied twice daily under occlusion using wet wraps. After 5 days of wet wrap therapy, significant improvement of the skin with desquamation of the adherent plaques on all sites of the body were noted. Although topical treatment is typically not effective in cases of rupioid psoriasis due to the thickness of the plaques, lack of patient compliance to an intensive topical treatment regimen may impact its historical ineffectiveness.5
The patient continued to improve with topical treatments over the next several weeks as she remained in the inpatient setting (Figure 4). The patient was eventually discharged to a skilled nursing facility due to overall deconditioning from her inpatient hospital stay.
Ms Papier is with Wake Forest University School of Medicine, department of dermatology, in Winston Salem, NC.
Dr Ahn is with Wake Forest University School of Medicine, department of dermatology, in Winston Salem, NC.
Dr Strowd is assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.
Disclosure: The authors report no relevant financial relationships.
References
1. Chung HJ, Marley-Kemp D, Keller M. Rupioid psoriasis and other skin diseases with rupioid manifestations. Cutis. 2014;94(3):119-121.
2. Salamon M, Omulecki A, Sysa-Jedrzeejowska A, McCauliffe DP, Wozniacka A. Psoriasis rupioides: a rare variant of a common disease. Cutis. 2011;88(3):135-137.
3. Koley S, Mandal RK, Chatterjee K, Hassan SM, Pathak S. Elephantine psoriasis with papillomatosis and alternating hypogranulosis and hypergranulosis. Indian J Dermatol. 2015;60(3):264-267.
4. Costa JB, Rocha de Sousa VL, da Trindade Neto PB, Paulo Filho, Tde A , Cabral VC, Pinheiro PM. Norwegian scabies mimicking rupioid psoriasis. An Bras Dermatol. 2012;87(60):910-913.
5. Feldman SR, Brown KL, Heald P. ‘Coral reef’ psoriasis: a marker of resistance to topical treatment. J Dermatolog Treat. 2008;19(5):257-258.
