A Difficult Diagnosis: What is Causing This Patient’s “Tree Bark” Rash?

Authors

Emmanuel Garcia, University of LynchburgFollow

Specialty

Family Medicine

Advisor

Dr. Laura Witte, PhD, PA-C

Abstract

An indigent obese 52-year-old African-American female presented to the primary care clinic wanting to establish care and complaining of a rash on both feet causing significant itching and stinging pain as well as generalized joint pain for many years. Upon further inspection, the rash was found to be generalized to the lower extremities, lower back, abdomen, hands, and scalp. The patient stated that the lesions had been present for at least a decade and had since gotten significantly worse with the joint pain also being present throughout her adult life. On physical exam, there were hyperpigmented hyperkeratotic plaques on her lower legs, hyperpigmented maculopapular rashes on the plantar surfaces of both feet, and hyperpigmented hyperkeratotic plaques on her torso, lower back, and scalp. There was no joint swelling, warmth, or erythema seen on the physical exam and strength was 5/5 at all extremities. No lymphadenopathy or Auspitz sign was found. The differential diagnosis included: Plaque Psoriasis, Fungal Skin Infection, Lichen Simplex Chronicus, and Lichen Planus. Utilizing a punch biopsy for identification of the rash, the unusual presentation was found to be Plaque Psoriasis and treatment was started using an injectable biologic which significantly increased quality of life.

Recommended Citation

Garcia E. A Difficult Diagnosis: What is Causing This Patient’s “Tree Bark” Rash?. University of Lynchburg DMSc Doctoral Project Assignment Repository. 2023; 5(2).