Primary Annular Plaque-Type Psoriasis

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Pediatric Dermatology Vol. 22 No. 1 15–18, 2005

Blackwell Publishing, Ltd.

Primary Annular Plaque-Type Psoriasis Carrie Lynn Guill, M.D.,* Mai P. Hoang, M.D.,† and K. Robin Carder, M.D.*

Departments of *Dermatology and †Pathology, University of Texas Southwestern Medical School, Dallas, Texas

Abstract: We described two adolescent girls with untreated, consistently annular, plaque-type psoriasis without pustules, a presentation that is to our knowledge, not previously described. No typical confluent plaque-type lesions were present. The plaques in our patients resembled other entities such as tinea corporis and erythema annulare centrifugum, given the erythematous, scaling borders and central clearing. Biopsy specimens from our patients showed features characteristic of psoriasis vulgaris. Both patients responded to combination therapy with calcipotriene and a mid-potency steroid. We conclude that primary annular plaque-type psoriasis shares features of both typical plaque-type and annular pustular psoriasis, suggesting that these entities represent a spectrum of psoriatic disease.

Plaque-type psoriasis typically presents as confluent erythematous plaques with silvery scale that have a predilection for the elbows, knees, extensor extremities, scalp, and lumbosacral areas. Occasionally, partially treated plaque-type psoriasis may transiently appear annular secondary to central clearing. Annular pustular psoriasis (APP) is a well-documented form of psoriasis characterized by primary annular erythematous pustulestudded plaques often occurring on the trunk, neck, and extremities. Although pustular psoriasis is rare in children, they are more likely to manifest annular lesions than adults (1–4). Primary, plaque-type, exclusively annular psoriasis has not been previously described, and we herein present two women who developed these lesions during adolescence.

CASE REPORTS Patient 1 A 20-year-old woman from Mexico had a 3-year history of well-demarcated, annular plaques on her trunk and extremities (Fig. 1). The patient reported that her skin lesions had always looked similarly and were nonpruritic. She denied ever noting pustules, vesicles, or desquamation. She also denied recurrent fevers, illnesses, or joint pain. She had never been treated with topical or oral medications for this condition, was in good health, and reported no family history of psoriasis. She had arrived in the United States a few months prior to presentation, and a primary care physician referred her to the dermatology department for treatment.

No funding was necessary to complete this manuscript.

No funding was necessary to complete this manuscript. The content of this manuscript has not been published previously, nor has it been submitted for publication. The authors have no conflict of interest to disclose. Address correspondence to K. Robin Carder, M.D., Department of Dermatology, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd., Dallas, TX 75390 –9069, or e-mail: [email protected].

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Figure 1. Patient 1: A well-demarcated, annular psoriatic plaque on the forearm.

Figure 3. Patient 2: The border of an annular psoriatic plaque on the back.

follow-up 2 months later, with no new lesions and decreased thickness of prior lesions. Patient 2

Figure 2. Hyperkeratosis, parakeratosis, hypogranulosis, psoriasiform hyperplasia, and spongiform pustules consistent with the diagnosis of psoriasis vulgaris. (hematoxylin and eosin, original magnification ×100).

On examination, the annular plaques had an erythematous base and fine white to silver scale. No typical confluent plaque-type lesions were noted. She also had several pits on her fingernails. The differential diagnosis on initial evaluation included tinea corporis, granuloma annulare, erythema annulare centrifugum, and psoriasis. A KOH (potassium hydroxide) preparation was negative. A 4-mm punch biopsy specimen was obtained from the border of an annular plaque on the arm. The histologic sections showed hyperkeratosis, parakeratosis, and collections of neutrophils in the stratum corneum (Munro microabscesses). The epidermis exhibited psoriasiform hyperplasia and hypogranulosis. These features were diagnostic of psoriasis (Fig. 2). The patient was treated with triamcinolone acetonide 0.1% ointment every morning and calcipotriene ointment every evening. Her skin lesions were much improved at

A 15-year-old African-American girl presented with a 10-year history of annular plaques on her chest, back, and extremities. The patient reported that her skin lesions had always been pruritic and in a ring-like configuration. She denied ever noting pustules, vesicles, or desquamation. She also denied recurrent fevers, illnesses, or joint pain. She had two biopsies of the lesions performed over the past 10 years. The specimen from the first showed psoriasiform dermatitis with spongiosis and the second had findings consistent with psoriasis. She had been treated with triamcinolone cream with minor improvement. She was in good health and reported no family history of psoriasis. On examination, erythematous, hyperkeratotic, annular, and arcuate plaques were noted on her arms, legs, and trunk. The differential diagnosis included tinea corporis, granuloma annulare, erythema annulare centrifugum, elastosis perforans serpiginosa, sarcoid, and psoriasis. A KOH preparation was negative. A 4-mm punch biopsy specimen was obtained from the border of an annular plaque on the inner thigh (Fig. 3). The histologic sections showed parakeratosis with collections of neutrophils, an epidermis with hypogranulosis and psoriasiform hyperplasia, and dermal blood vessels approaching the epidermis (Fig. 4). These features confirmed the diagnosis of psoriasis. She was treated with triamcinolone acetonide 0.1% ointment every morning and calcipotriene ointment every evening. Months after beginning treatment, the lesions showed much improvement with only a few remaining thin lesions and several areas of postinflammatory hyperpigmentation.

Guill et al: Annular Psoriasis 17

Figure 4. Parakeratosis with collections of neutrophils, hypogranulosis, psoriasiform hyperplasia, and dermal blood vessels approaching the epidermis which confirms the diagnosis of psoriasis. (hematoxylin and eosin, original magnification ×200).

DISCUSSION Annular pustular psoriasis is the only primary annular presentation of psoriasis previously described in the literature. Nonpustular annular psoriatic plaques have been alluded to in a few reports. In a review of 1262 children with psoriasis, Morris et al (5) mentioned an annular nonpustular type of psoriasis; however, details of the cases were not given. Abel et al (6) explained that central portions of some psoriatic plaques may involute after topical treatment and, as a result, transient circinate and arcuate lesions are formed. Primary presentation of annular psoriatic plaques without pustules has never been described, and the annular configuration has only been shown to occur transiently when plaque-type lesions are treated topically. Our two adolescent patients had untreated, nonpustular, consistently annular plaques of psoriasis that differed considerably from APP.

Although rare, APP occurs in all ages, but affects a relatively higher proportion of the younger population. Liao et al (1) reviewed 137 reported patients with pediatric (under 20 years of age) pustular psoriasis in which lesion configuration was known. Nearly 60% (78 patients) had annular lesions, of which 78% (61 patients) had solely APP and 22% (17 patients) had a mixture of generalized pustular psoriasis (GPP) and APP. Adler et al (3) described APP as gyrate, annular lesions with an erythematous, scaly, and pustular margin. Like GPP, fever and leukocytosis may accompany the onset of pustules; however, APP has a more benign course (3) and can be intermittent over years. The recurrent, annular plaques are characterized by an erythematous, scaly, pustular margin that desquamates within 24 hours (1,3). Complete resolution usually occurs within days to weeks, but may take many months (4,7). Pustules may be transient clinically, but biopsy specimens of older lesions may still show neutrophils in the subcorneal layer of the epidermis without spongiform changes (3). The skin lesions of our patients lack many characteristic features of annular pustular psoriasis, including pustules and desquamation at the margin of the plaques, an intermittent course, and histologic features, such as macropustules. Our patients had an onset of annular plaques at between the ages of 5 and 15 years, which persisted for years until properly diagnosed and treated. They both responded to the combination of triamcinolone acetonide 0.1% ointment and calcipotriene 0.005% ointment within weeks to months. The plaques in our patients closely resembled tinea corporis, given the erythematous, scaling border and central clearing. The differential diagnosis of annular plaques would also include: granuloma annulare, erythema annulare centrifugum, elastosis perforans serpiginosa, sarcoid, nummular eczema, urticaria, subacute cutaneous lupus, and erythema multiforme (1). These entities can be distinguished on the basis histopathologic examination findings. The major histologic features shared by APP and typical plaque-type psoriasis include confluent parakeratosis, acanthotic epidermis with regular elongation of rete ridges, focal epidermal edema, epidermal spongiform pustules, dilatation of superficial dermal capillaries, and an infiltrate of mononuclear cells and neutrophils in the upper dermis (1,3,8). These histologic features were observed in both patients. The spongiform pustules of Kogoj, which are very small micropustules in early active lesions of psoriasis vulgaris, occur as macropustules in pustular psoriasis and are one histologic feature that distinguishes pustular from

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plaque-type psoriasis (8). Skin specimens from our patients lacked the characteristic macropustules of pustular psoriasis. Nearly all forms of psoriasis have been described in children and adolescents. Plaque-type psoriasis is the most common in all age groups (79%) (9), and accounts for 41% to 78% (5,9,10) of pediatric and early onset psoriasis. Guttate psoriasis, which often manifests as an eruption of small teardrop-shaped papules and plaques following a streptococcal throat infection (11,12), is the next most common in the pediatric population, affecting 8% to 26% (5,9,10) of patients. Rare forms in children and adolescents include: intertriginous (inverse), pustular (localized and generalized), and erythrodermic psoriasis (12). Our patients’ lesions have a unique morphologic form with features of plaque-type psoriasis, but with distinct central clearing and annular configuration of the plaques. This is unusual considering the plaques were consistently annular and were not a result of any previous treatment. Annular plaque-type psoriasis has a broad differential diagnosis and may be confused with other entities, such as tinea or erythema annulare centrifugum. Primary, annular, plaque-type psoriasis shares features of both plaque-type and annular pustular psoriasis; thus, these presentations may represent different poles within a spectrum of psoriatic disease.

REFERENCES 1. Liao PB, Rubinson R, Howard R, et al. Annular pustular psoriasis – most common form of pustular psoriasis in children: report of three cases and review of the literature. Pediatr Dermatol 2002;19(1):19–25. 2. Rongioletti F, Casciaro S, Boccaccio P, et al. Annular pustular psoriasis and systemic lupus erythematosus. Int J Dermatol 1990;29(4):290–292. 3. Adler DJ, Rower JM, Hashimoto K. Annular pustular psoriasis. Arch Dermatol 1981;117(5):313–314. 4. Rosen RM. Annular pustular psoriasis induced by UV radiation from tanning salon use. J Am Acad Dermatol 1991;25(2 Part 1):336–337. 5. Morris A, Rogers M, Fischer G, et al. Childhood psoriasis: a clinical review of 1262 cases. Pediatr Dermatol 2001;18(3):188–198. 6. Demis DJ, ed. Clinical Dermatology, 19th edn. Philadelphia: JB Lippincott, 1972. 7. Resneck JS, Cram DL. Erythema annulare-like pustular psoriasis. Arch Dermatol 1973;108(5):687–688. 8. Elder D, ed. Lever’s Histopathology of the Skin, 8th edn. Philadelphia: Lippincott-Raven, 1997. 9. Ferrandiz C, Pujol RM, Garcia-Patos V, et al. Psoriasis of early and late onset: a clinical and epidemiologic study from Spain. J Am Acad Dermatol 2002;46(6):867–873. 10. Nanda A, Kaur S, Kaur I, et al. Childhood psoriasis: an epidemiologic survey of 112 patients. Pediatr Dermatol 1990;7(1):19–21. 11. Christophers E, Kiene P. Guttate and plaque psoriasis. Dermatol Clin 1995;13(4):751–756. 12. Farber EM, Nall L. Childhood psoriasis. Cutis 1999;64(5):309–314.

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