Race for the Case

Race for the Case is a clinical quiz feature published quarterly in DermWorld Directions in Residency — and right here!

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Winter 2020 case by Julia Escandon Brehm, MD, PhD

A 23-year-old woman with a history of ulcerative colitis (UC) presented with a 3-week history of a pustular rash on the palms and soles that is intermittently pruritic but not painful. The patient had been on infliximab for her UC for 7 months when the rash appeared. Infliximab was stopped due to concern for a paradoxical drug-related reaction. Histopathological evaluation of a lesion on the left palm demonstrated a subcorneal bulla with neutrophils, and Periodic-acid Schiff stain was negative for fungal organisms. She was started on topical steroids and cyclosporine 100mg twice daily. After one month on this treatment regimen, the rash improved significantly but did not completely resolve. The patient has recently been started on ustekinumab to manage her UC.

1. What is the diagnosis?

2. What factors support this diagnosis over a diagnosis of palmoplantar psoriasis?

3. What factor(s) in this patient’s history likely contributed to the development of this condition?

4. What information is important to elicit from this patient’s social history that is associated with the development of this condition?

5. Name some potential treatment options.

6. How is the pustular rash expected to evolve with the addition of an anti-IL-12/23 agent (ustekinumab)?

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