I am a 41-year-old male, an old case of ankylosing spondylitis and was on Methotrexate for 10 years, then switched over to injection Exemptia and after six month of injections, I started developing skin rashes and dryness and lost hairs on my both the legs only on the outer side. I have dryness and itching on my hips both the sides, on neck underneath jaw on both the sides. One rheumatologist suspected psoriasis, while dermatologists said dry skin. Injection Exemptia was stopped immediately after I develop nose infection which some ENT people diagnosed as vestibulitis while other said anterior atrophic rhitnitis. I was switched back to Methotrexate and gradually I had to stop that due to chronic nose problems. I am on long term nasal antibiotic ointments. Once I stop it nose problem immediately worsens. Joint pain is still there but mild. I have stopped Exemptia for more than a year and Methotrexate for more than six months. Still my nose issue is persisting. I started developing tiny pustules around my nose and face, chin, neck, and on thighs as well.
I am attaching all the images. Please let me know if it is psoriasis or pustular form of psoriasis or chronic furunculosis or some other condition. Which investigations are required? Do I need antibiotics or immunosuppression?
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I have seen the images (attachment removed to protect patient identity).
I went through your case which is indeed a chronic one and has a lot of other manifestations in skin too. Ankylosing spondylitis is commonly associated with psoriasis and so other vasculitis which may present as furuncles. But it is not a pustular psoriasis. That is different. Dry scaly lesions over hips and legs do look like psoriasis. However, confirmation will be done on clinical examination by looking scales. If confirmed by a dermatologist, it is so.
As you have left Methotrexate and Adalimumab long back, they are out of body and not the cause. It is reccurrent folliculitis which is due to genetic deficiency to fight a bacteria called staphyloccus. You did not comment on response to Doxycycline and Cefatoxime. Doxycycline is a good drug to control it during exacerbations then Mupirocin and precautions as follows.
Ankylosing spondylitis.Investigations to be done:
For confirmation, biopsy for psoriasis. Pus culture sensitivity for furuncles.Differential diagnosis:
Leucocytoclastic vasculitis.Probable diagnosis:
Recurrent folliculitis and Psoriasis.Treatment plan:
For furunculosis, tablet Azithromycin 500 mg once daily before breakfast for seven days, Mupirocin ointment daily twice over the lesions for one month. Aloevera lotion after bath all over.
Keep emoliated by coconut oil. Avoid touching your face or other body part unnecessarily.
Avoid harsh soaps.Regarding follow up:
After four weeks.
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