Psoriasis Guttata with Palmoplantar Involvement Clinically Mimicking Secondary Syphilis
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Psoriasis Guttata With Palmoplantar Involvement Clinically Mimicking Secondary Syphilis Whitney A. High, MD; Mai P. Hoang, MD; Paul R. Bergstresser, MD Papulosquamous eruptions involving the palms involvement and a remissive course strongly sug- and soles are thought to be particularly sugges- gested secondary syphilis. Results of serologic testing, tive of secondary syphilis. Alternative diagnoses however, demonstrated no evidence of treponemici- exist, however, and include psoriasis guttata, dal antibodies. Results of histopathologic examination atypical pityriasis rosea, and pityriasis lichenoides included psoriasiform dermatitis with neutrophils chronica (PLC). We describe the case of a patient in the epidermis. Plasma cells were conspicuously with an abrupt onset of psoriasis guttata and absent, and the results of silver and immunohisto- extensive palmoplantar involvement. Results of chemical staining for spirochetes did not demonstrate serologic testing were negative for treponemicidal organisms in the tissue. antibodies. Results of histopathologic examination demonstrated psoriasiform dermatitis with neu- Case Report trophils in the epidermis; plasma cells were A 27-year-old black woman presented to the derma- absent. Spirochetes were not demonstrated in a tology clinic of Parkland Memorial Hospital in tissue sample using silver or immunohistochemi- Dallas, Texas, with a rash of 4 weeks’ duration. The cal stains for Treponema pallidum. A broad differ- diffuse eruption had had an abrupt onset. The patient ential diagnosis is required when evaluating denied prodromal symptoms such as fever, arthralgias, papulosquamous eruptions with palmoplantar sore throat, or upper respiratory illness. Although dis- involvement. Although not well referenced in the tressing in appearance, the rash was asymptomatic. medical literature, psoriasis guttata can indeed There was no personal or family history of skin dis- cause palmoplantar lesions that mimic those of ease. The patient had been in a monogamous sexual secondary syphilis. relationship for 2 years. Cutis. 2005;76:358-360. On physical examination, the patient exhibited an extensive papulosquamous eruption on the trunk and extremities that consisted of erythematous scaling apulosquamous eruptions involving the palms papules and small plaques (Figure 1). Palmoplantar and soles are thought to be highly suggestive involvement also was noted (Figure 2). Her elbows, P of secondary syphilis.1 Nevertheless, alternative knees, scalp, and gluteal cleft were not extensively diagnoses include psoriasis guttata, atypical pityriasis involved. Her fingernails showed no pitting, discol- rosea, and pityriasis lichenoides chronica (PLC), oration, or onycholysis. The oral mucosa appeared all of which occasionally exhibit palmoplantar normal. Clinical suspicion of secondary syphilis was involvement.2-4 We describe the case of a patient with high, but additional studies were needed to confirm an abrupt onset of psoriasis guttata. Palmoplantar a diagnosis. Despite serial dilution to prevent a confounding Accepted for publication September 9, 2004. prozone phenomenon, results of a rapid plasmin Dr. High is from the Department of Dermatology, University of Colorado Health Sciences Center, Denver. Dr. Hoang is from reagin/VDRL test did not demonstrate nonspecific the Department of Pathology, and Dr. Bergstresser is from the antibodies to Treponema pallidum, and the findings Department of Dermatology, University of Texas Southwestern of the microhemagglutination–T pallidum test did Medical Center at Dallas. not reveal specific antibodies to the organism. Test The authors report no conflict of interest. results were negative for human immunodeficiency Reprints: Whitney A. High, MD, Department of Dermatology, University of Colorado Health Sciences Center, PO Box 6510, virus. Results of a 6-mm punch biopsy from the left Mail Stop F.703, Denver, CO 80045-0510 upper thigh revealed psoriasiform dermatitis with a (e-mail: [email protected]). sparse perivascular lymphocytic infiltrate; plasma 358 CUTIS® Psoriasis Guttata With Palmoplantar Involvement Figure 1. Diffuse papulosquamous eruption on the Figure 2. Limited papulosquamous small plaques on proximal extremities of a 27-year-old black woman volar surface of the hands of the same patient. With one month after abrupt onset. treatment, complete resolution occurred within 3 months. cells were not prominent. Focal parakeratosis was some streptococcal products and components have demonstrated, as was focal diminution of the granular been found to cross-react with normal human epi- layer. Neutrophils were noted within the epidermis dermis.10,11 T cells and evolved cytokines, or super- and the stratum corneum epidermidis. Results of sil- antigens, are believed to cause the characteristic ver staining and immunohistochemical staining with inflammatory changes seen on histopathologic monoclonal antibodies were negative for T pallidum. examination.12,13 The patient was treated with oral cephalexin Microscopic findings in psoriasis guttata vary and 500 mg 4 times per day for 14 days, because the staff include mild epidermal hyperplasia; focal spongiosis; thought that subclinical streptococcal infection may disappearance of the granular layer; and exocytosis have played a role in initiation of psoriasis guttata; of neutrophils, which migrate into the epidermis triamcinolone 0.1% ointment was applied to the to produce epidermal or subcorneal collections affected papules and plaques twice a day. After one known as spongiform pustules of Kogoj or Munro month, marked clinical improvement was noted. By microabscesses, respectively.14 3 months, the patient noted complete resolution of Other conditions that should be considered in the eruption. On physical examination, only an the differential diagnosis include secondary syphilis, asymptomatic keloid at the biopsy site and trans- PLC, and atypical pityriasis rosea. In this case, sec- verse onychomalacia (Beau lines) 6 to 8 mm from ondary syphilis was of particular concern given the the proximal nail fold were noted. substantial involvement of the palms and soles. Results of both rapid plasmin reagin test and a Comment microhemagglutination–T pallidum test to screen for Psoriasis guttata is a relatively rare form of psoriasis, specific antibodies to T pallidum were negative. accounting for just 2% to 10% of all cases.5,6 It may be These serologic tests possess nearly 100% sensitivity substantially more common in children.7 The classic in secondary syphilis.15,16 Because of the high rate presentation consists of an abrupt onset of small, dif- of syphilis infection in patients seen at Parkland fuse, salmon-colored, papulosquamous papules with Memorial Hospital, serial dilutions to prevent pro- silver scale.6 The appellation is derived from the zone phenomenon are routinely performed.17 Latin word gutta, which means a drop, and the clini- Microscopic examination of the biopsy specimen cal presentation often justifies this morphologic anal- did not demonstrate the presence of plasma cells, ogy. Primarily a disease of youth, psoriasis guttata which are characteristic of secondary syphilis. typically affects persons younger than 30 years. The Results of silver staining were normal, as were those trunk and proximal extremities are commonly of immunohistochemical staining with antibodies involved. Lesions on the palms and soles have been to T pallidum, a technique known to increase sensi- documented rarely in the literature.2 tivity.18,19 PLC tends to follow a more protracted The pathophysiologic mechanism underlying clinical course than psoriasis guttata, and the psoriasis guttata is undetermined. Streptococcal histopathologic findings in PLC often include focal infection in the weeks prior to eruption is a com- interface dermatitis, dyskeratotic cells, and monly suspected trigger.8,9 Autoimmune and molec- extravasated red blood cells—none of which were ular mimicry phenomena have been postulated, and observed in this case.4 VOLUME 76, DECEMBER 2005 359 Psoriasis Guttata With Palmoplantar Involvement Atypical pityriasis rosea, more common in blacks 8. Whyte HJ, Baughman RD. Acute psoriasis and streptococ- than in whites, rarely involves the palms and soles.3 cal infections. Arch Dermatol. 1964;89:350-356. On clinical examination, the lesions of pityriasis 9. Telfer NR, Chalmers RJ, Whale K, et al. The role of strep- rosea demonstrate a more delicate peripheral scale. tococcal infection in the initiation of guttate psoriasis. Arch A herald patch, not noted by our patient, occurs in Dermatol. 1992;128:39-42. more than 50% of cases.20 Results of histopathologic 10. Perez-Lorenzo R, Zambrano-Zaragoza JF, Saul A, et al. examination of lesions in pityriasis rosea usually Autoantibodies to autologous skin in guttate and plaque show mounds of parakeratosis and extravasated red forms of psoriasis and cross-reaction of skin antigens with blood cells, which were not seen in our case.21 Neu- streptococcal antigens. Int J Dermatol. 1998;37:524-531. trophils in the stratum corneum epidermidis, present 11. Villeda-Gabriel G, Santamaria-Cogollos LC, Perez-Lorenzo in this case, militate against pityriasis rosea and R, et al. Recognition of Streptococcus pyogenes and skin instead favor psoriasis guttata, though the difficulty autoantigens in guttate psoriasis. Arch Med Res. in discriminating between these 2 diseases is well 1998;29:143-148. documented.21,22 12. Baker BS, Bokth S, Powles A, et al. Group A streptococcal In conclusion, papulosquamous