Practice Connection: Family Medicine Question Explained

Hi, I’m Andrea Paul and today we’re going to be talking through one of the BoardVitals questions. This time, this is a family medicine question bank question. So I’ll go ahead and read the question. It is a 45 year-old man with a past medical history of Crohn’s disease. He’s presenting with a recurring rash that has lasted several years. This rash consists of lesions, they’re scaly and silver in color, they occur over his elbows over his knees and above his gluteal cleft. and they come and go over several months. He’s never been able to identify any trigger. No fever, chills, nausea and no other symptoms. His temperature is normal and his vitals are within normal limits but this exam does show this silvery, scaly plaque. over his elbows and knees. There’s a photo shown in this question that should really help you figure out what this diagnosis might be. You also note that he has punctate bleeding when one of the scales is removed from this lesion. The question is what is the most likely diagnosis? The options are Psoriasis, Pityriasis rosea, Contact dermatitis, Milaria rubra, or Lichen planus. and so right away the things that should stick out to you are the silvery plaque and the punctate bleeding. when you remove part of the scale. and those are classic buzz words that will lead you to Psoriasis. So just a little discussion about Psoriasis in general and what you might see on an exam question. So it’s a chronic, inflammatory skin disease. It’s characterized by well demarcated, erythematous plaques with a silver scale. So that’s the classic finding. They look very much like the picture in this question The most common type is chronic plaque Psoriasis. And so this variant basically has symmetrical distributions so you’ll see it over both elbows or both knees In a really symmetrical distribution with that classic, sharply demarcated or arthemitis with the silver scale. And so sometimes if they had put on a lotion or an oil, that silvery scale will look a little more erythematous and less white and silvery. But that’s only temporary so once it’s dry it will have that same silvery, scaly appearance again. They can really range in size so you can have a once centimeter plaque, or ten or more centimeters in diameter. Usually, asymptomatic but some people complain about itching around the area. Sometimes it can be painful if they have it on their palms and say that it’s an area that they use a lot and it may crack so there could be some pain or even disability from inability to use your hands if it does get to that point. So the classic thing, which is called Auspitz sign is that when you peel away one of these silvery plaques you’ll have punctate, so little tiny dots of bleeding. Like little pin points. And that’s a really classic, clinical finding so that should help you find the answer to this question too.

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