Endgames Picture Quiz

A 41 year old man with an itchy rash

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7320 (Published 17 November 2011) Cite this as: BMJ 2011;343:d7320
  1. Rebekka Salgo, consultant dermatologist,
  2. Wolf-Henning Boehncke, professor of dermatology
  1. 1Department of Dermatology, JW Goethe-University Frankfurt, 60590 Frankfurt, Germany
  1. Correspondence to: R Salgo rebekka.salgo{at}kgu.de

A 41 year old man presented with a widespread rash that had been recurrently itchy and uncomfortable for 20 years. He also had stiff and painful fingers, mainly during the morning and most pronounced towards the fingertips; these symptoms had got worse over the past few months.

On examination, he showed disseminated, sharply demarcated, red, scaly plaques; these were accentuated over his elbows, knees, and trunk (fig 1). He was 166 cm tall, weighed 98 kg, and had been obese since adolescence. He had been taking zuclopenthixol because of depression for the past five years, had smoked one pack of cigarettes a day for many years, and had a daily alcohol intake of 1-2 L of beer. He had no other relevant medical history.


  • 1 What is your diagnosis regarding the patient‘s skin disease?

  • 2 What other comorbidities are associated with this skin condition?

  • 3 What is the importance of the joint symptoms?

  • 4 How could the diagnosis of depression influence the management of this patient?

  • 5 How would you treat this patient?


1 What is your diagnosis regarding the patient‘s skin disease?

Short answer

The patient has plaque-type psoriasis.

Long answer

Psoriasis is a chronic recurrent immune mediated inflammatory skin disease with a prevalence of 2-3% in Europe and northern America.1

Several different types exist. The most common manifestation, plaque-type psoriasis, is characterised by sharply demarcated red plaques covered by silvery scaling (fig 2). Lesions are typically located at the knees, elbows, lower back, and head but may at times affect the whole body surface. Children often develop rashes consisting of small red papules on the trunk, known as guttate psoriasis (fig 3), which may be triggered by …

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