An embarrassing rash

10 z Prescriber December 2013 prescriber.co.uk Working as a concierge in a four-star hotel had become increasingly stressful for this 30-year-old overweight man with psoriasis, not least because the requisite black uniform highlighted the thick scale that flaked from his scalp, the unpredictable hours made regular application of creams almost impossible and smoking breaks were the only chance to leave the building in an 18hour shift. This environment only served to make his psoriasis worse. The itchy, burgundycoloured, indurated plaques congregated around his shins and forearms with a thick, yellowing scale. However, the area that caused him the most distress was his hands: the angry, erythematous palms with tense pustules, with scattered erythematous plaques on the dorsum, had begun to attract comments at work and had stopped him from socialising all together due to embarrassment. He had been using beclometasone 0.1 per cent ointment and emollients with salicylic acid, but had experienced little relief. He had also been recently diagnosed with psoriatic arthritis particularly affecting his knees and hips and had been reviewed by rheumatology who had recommended methotrexate. Unfortunately, his liver function was deranged and therefore this option was excluded. He was seen in the dermatology clinic at which point his Psoriasis Area Severity Index (PASI) was 14.5 and Dermatology Life Quality Index (DLQI) 16, suggesting a significant skin involvement and impact of the psoriasis on his quality of life. He was unable to attend phototherapy due to work commitments and was eligible for biological agents. He was therefore commenced on adalimumab (Humira). Three weeks after initiating treatment both his psoriatic plaques and joint pains had significantly improved. He continues to be monitored and six An embarrassing rash