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Description
A 56-year-old woman presented to the hand clinic, with a 6-month history of progressive painful and swollen acra, resulting in a weakened grip. Her medical history included psoriasis vulgaris since 2006, with progressively worsening skin abnormalities. She could not relate the symptoms to any history of trauma. On examination, she had painful and swollen digits 1 and 3 on the left and digits 1, 3 and 4 on the right hand, including typical nail abnormalities (figure 1). C reactive protein, erythrocyte sedimentation rate and parathyroid hormone were not raised. Radiographs and MRI showed severe osteolytic lesions of the distal phalanx of digits 1 and 3 on the right and digit 1 on the left hand (figure 2). Additionally, a technetium bone-scan and single photon emission CT showed increased activity in several terminal phalanges (figure 3). A biopsy of the right index finger showed an inflammatory reactive process, with no signs of malignancy. In summary, we present a case of severe acro-osteolysis psoriatica. In response to our conclusion, the dermatologist started light therapy and reserved the option of using methotrexate.
Our patient was diagnosed with acro-osteolysis, a rare presentation of osteolysis of the distal phalanges seen in a number of conditions including psoriasis vulgaris, Ehlers-Danlos syndrome, systemic sclerosis, leprosy, sarcoidosis and rarely in Raynaud's disease.1 ,2 The exact incidence, prevalence and pathogenesis is unclear.1 ,2
Learning points
Acro-osteolysis psoriatica is a reactive form of osteolysis of mainly the distal phalanges. Acro-osteolyis is seen in a number of conditions including psoriasis, Ehlers-Danlos syndrome, systemic sclerosis, leprosy and vinyl chloride disease.
Patients with psoriasis, worsening skin abnormalities, nail abnormalities and painful swollen acra should be treated in a multidisciplinary (dermatologist, intern doctor, orthopaedic surgeon) setting.
Footnotes
Contributors SM wrote the article, performed the literature search and is the guarantor. GK identified the case, conceived the idea for and reviewed article and are the corresponding authors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.