In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief complaint: presenting for diagnosis and therapeutic options.
History of Present Illness
A 32-year-old lady presents with a rash on her bilateral inguinal folds that has progressively worsened over the last 6 months. She is a patient with poorly controlled diabetes (hemoglobin A1C = 9.4). Prior treatment for skin condition: clotrimazole 1% cream over-the-counter BID (twice per day) for 10 weeks with minimal improvement. Her primary symptom: soreness. Prior biopsy: none.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
There is one image provided with this consult. The image shows a large, pink plaque with a central fissuring and maceration, involving the left inguinal fold. There are no satellite lesions to suggest candidal infection. There is no sparing of the internal crease to suggest irritant contact dermatitis (see Figure 1).
INTERPRETATION OF IMAGES
Lesion A
Findings
The morphology of the lesions, distribution, and history are characteristic of inverse psoriasis.
RECOMMENDATIONS
Skin Care Recommendations
The area needs to be kept clean and dry. Soft cotton can be used to prevent skin-to-skin contact and provide wicking of perspiration. Gentle cleansers should be used, followed by patting dry and application of a zinc paste-based barrier cream.
Medication Recommendations
First-line treatment is low-potency topical steroids (e.g., triamcinolone 0.025% cream twice a day) for a limited duration of time (<2-4 weeks). Extended use of topical corticosteroids must be avoided because of adverse effects such as skin atrophy and striae, especially in the intertriginous areas.
Chronic inverse psoriasis (>4 weeks) can be treated with calcipotriene (percentage in vehicle and frequency) or other topical immunomodulating agents such as calcineurin inhibitors (e.g., pimecrolimus 1% cream BID or tacrolimus 0.03% ointment BID; Kivelevitch, Frieder, Watson, Paek, & Menter, 2018).
RECOMMENDED FOLLOW-UP
Please refer to dermatology for face-to-face evaluation if no improvement in 4-6 weeks.
CLINICAL PEARL
Inverse psoriasis is a form of psoriasis that affects the intertriginous areas or folds of the body (Habashy, 2018). It is not considered to be a separate disease from psoriasis but rather a regional variant (Syed, 2011). Psoriasis is a multifactorial disease that is caused by a genetic predisposition and environmental triggers. A dysfunctional interaction between the innate and adaptive immune systems causes abnormal T-cell activation, which results in inflammation and hyperproliferation of keratinocytes (Jain, 2012). It has been estimated that 2%-6% of patients with psoriasis experience symptoms involving the intertriginous areas (Guglielmetti, Conlledo, Bedoya, Ianiszewski, & Correa, 2012).
Clinically, inverse psoriasis presents as erythematous, inflamed, or red plaques within the flexural regions of the body. Areas that are commonly affected include the inguinal folds, axillae, and external genitalia. In the inguinal folds, it is often mistaken for candida or dermatophyte infections and treated inadequately with several antifungals before appropriate diagnosis as inverse psoriasis. The disease is visually distinct from general psoriasis in that it appears shiny and moist, lacking the classic thick, scaly appearance (Syed & Khachemoune, 2011). Because of the topographical location of inverse psoriasis, friction and perspiration play a role in the exacerbation of these lesions. Fissures or maceration of the tissue often occurs (Guglielmetti et al., 2012). The warm, moist conditions of the intertriginous areas also provide a favorable environment for secondary bacterial and fungal infections (Syed & Khachemoune, 2011).
REFERENCES