Dermatology Consultation Note

Diagnosis

1. Worsening extensor rash

• Chronic plaque psoriasis
• Discoid eczema, cutaneous T-cell lymphoma
• Baseline fasting lipids, HbA1c, FBC, U&Es, and LFTs
• calcipotriol 50 mcg/g / betamethasone dipropionate 0.5 mg/g (Enstilar®) cutaneous foam OD for 4 weeks; Cetraben® cream PRN
• Rheumatology referral (given mild early morning stiffness in DIP joints)

2. Pigmented lesion on left upper back

• Benign compound melanocytic naevus
• Dysplastic naevus, superficial spreading melanoma
• Dermoscopy performed today; baseline clinical photography
• Reassurance and sun protection advice
• None required

3. Facial erythema and papules

• Papulopustular rosacea
• Seborrhoeic dermatitis, periorificial dermatitis
• None required
• ivermectin (Soolantra®) 10 mg/g cream TOP OD at night for 12 weeks
• None required

Treatment

For chronic plaque psoriasis, Mr Arthur Pendelton will commence calcipotriol 50 mcg/g / betamethasone dipropionate 0.5 mg/g (Enstilar®) cutaneous foam applied topically OD to affected plaques on the trunk and limbs for 4 weeks, stepping down to twice-weekly maintenance on weekends thereafter. This is anticipated to induce rapid plaque clearance and reduce pruritus. Possible adverse effects discussed include local skin atrophy, striae, telangiectasia with prolonged use, and rebound flaring if stopped abruptly. Liberal use of Cetraben® ointment or cream PRN as a soap substitute and general emollient was advised. For papulopustular rosacea, he will start ivermectin (Soolantra®) 10 mg/g cream applied topically OD to the face at night for 12 weeks to reduce inflammatory papules, noting potential mild transient skin irritation upon initiation.

Note to the GP: please continue prescribing the above treatment when needed. Please arrange the following investigations because the patient is self-funding: FBC, U&Es, LFTs, HbA1c, and fasting lipid profile (cardiovascular risk screening and baseline prior to potential systemic therapy).

Follow-up

Clinic review in 12 weeks to assess response to topical therapy and consider narrowband UVB phototherapy or systemic agents (e.g., methotrexate) if psoriasis remains refractory.

Investigations

Dermoscopy of left scapular lesion and baseline medical photography of psoriasis plaques and back naevus performed today. Request sent to GP for baseline blood tests (FBC, U&Es, LFTs, lipids, HbA1c).

12/08/2023: Skin punch biopsy (right elbow plaque) demonstrated regular acanthosis, parakeratosis, Munro microabscesses, and dilated dermal capillaries, consistent with plaque psoriasis. 14/10/2021: Patch testing to British Standard Series showed positive (++) reaction to nickel sulphate at 48 and 96 hours.

Past Skin History

12/08/2023: Diagnosed with mild plaque psoriasis affecting elbows and knees; managed effectively at the time with betamethasone valerate (Betnovate®) 0.1% ointment OD and emollients. 14/10/2021: Allergic contact dermatitis secondary to metal watch strap; resolved following nickel avoidance and short course of hydrocortisone 1% cream.

Past Medical History

2018: Diagnosed with chronic migraine without aura, currently under neurology follow-up and well-controlled on prophylactic therapy. 2016: Diagnosed with essential hypertension, managed in primary care with stable blood pressure readings. 2012: Underwent laparoscopic appendicectomy with no postoperative complications.

Medication

propranolol 80 mg modified-release PO OD (for migraine prophylaxis), amlodipine 5 mg PO OD, sumatriptan 50 mg PO PRN, hydrocortisone 1% cream TOP PRN (stopped today), colecalciferol (vitamin D3) 1,000 IU PO OD.

Allergies

Penicillin (maculopapular rash), nickel sulphate (allergic contact dermatitis).

Family History

Father has severe chronic plaque psoriasis and psoriatic arthritis. Maternal aunt had a basal cell carcinoma excised from the nose at age 68. Sister has atopic eczema and seasonal allergic rhinitis.

Social History

Mr Pendelton works indoors as a chartered accountant. He takes one holiday abroad to southern Europe annually and uses SPF 30 sunscreen intermittently, with no history of sunbed use or blistering sunburns. He washes daily with standard perfumed shower gel. He drinks approximately 10 units of alcohol per week, is a lifelong non-smoker, and swims twice weekly at a local chlorinated pool.

I reviewed the above 46 year old gentleman. My clinical notes from today are as follows:

Subjective

Mr Arthur Pendelton attended today regarding a significant flare of his plaque psoriasis, an evolving mole on his left upper back noticed by his partner, and persistent central facial redness.

His psoriasis has progressively worsened over the past 3 months, expanding from his elbows and knees to involve his lower back, buttocks, and shins. The plaques are moderately pruritic, occasionally crack and bleed over the knees, and shed significant scale onto his clothing and bedding. He noted the flare coincided with increasing his propranolol dose for migraine prophylaxis 4 months ago and a period of high work-related stress. Over-the-counter emollients and leftover hydrocortisone 1% cream have provided no meaningful relief.

He also requested a check of a pigmented lesion over his left scapula, which his partner noted recently, though they are unsure if it has changed in size, shape, or colour; it is entirely asymptomatic with no bleeding, oozing, or crusting. Additionally, he reported a 6-month history of flushing and small red spots across his cheeks and nose.

The psoriatic plaques are present continuously, whilst the facial flushing is episodic and lasts several hours at a time, localized strictly to the malar region and nasal bridge.

His psoriasis symptoms are aggravated by cold weather, stress, and swimming in chlorinated water, while warm baths and thick ointments offer temporary soothing. His facial redness is triggered by hot beverages, red wine, and spicy foods; he tried applying hydrocortisone 1% cream to his face for 2 weeks, which initially blanched the redness but caused a rebound flare upon cessation.

Whilst his psoriasis previously remained localized and mild, the current trajectory shows steady expansion in body surface area over the last 12 weeks.

Previous flares in 2023 were limited to the extensor elbows and cleared within 3 weeks of using potent topical corticosteroids prescribed by his GP.

The visibility of the plaques and facial redness causes him self-consciousness during client meetings, and he has stopped swimming due to embarrassment and skin stinging.

He reports mild early morning stiffness in the distal interphalangeal joints of both hands lasting 15 minutes, though he has no dactylitis, Achilles tendon pain, or systemic symptoms such as fever, night sweats, or weight loss.

Objective

BP 128/78 mmHg, HR 62 bpm, BMI 27.4 kg/m².

Fitzpatrick skin type II. Well-demarcated erythematous plaques with thick silvery-white scale distributed symmetrically over the extensor elbows, knees, presacral area, and anterior shins (BSA 8%, PASI 7.2). Auspitz sign positive on the right elbow. Scalp shows mild occipital scaling. Nails show discrete pitting on the right index and ring fingernails, with no onycholysis or subungual hyperkeratosis. Central face exhibits background telangiectatic erythema over the cheeks and nasal bridge with scattered inflammatory papules and occasional pustules; no comedones are present, and the periorbital skin is spared. On the left upper back, there is a 5 mm x 4 mm symmetrical, uniformly light-brown macule with regular borders.

Dermoscopy of the left scapular lesion reveals a regular reticular pigment network with uniform globules at the periphery and no atypical features (no blue-white veil, regression structures, or atypical vessels).

Assessment

1. Chronic plaque psoriasis flare, potentially exacerbated by beta-blocker therapy (propranolol) and recent stress. We will treat this topically with calcipotriol/betamethasone dipropionate (Enstilar®) foam OD for 4 weeks alongside regular Cetraben® emollient therapy.

Mr Pendelton was advised to switch from perfumed shower gel to Cetraben® as a soap substitute, apply barrier emollient prior to swimming to reduce chlorine irritation, and moderate alcohol intake. We also discussed speaking with his neurologist or GP regarding potential alternatives to propranolol (such as candesartan or amitriptyline) for migraine prophylaxis if his skin remains difficult to control.

I will review Mr Pendelton in the dermatology clinic in 12 weeks to evaluate clearance and discuss phototherapy if required.

Given the new nail pitting and mild DIP joint stiffness, I have recommended a routine referral to Rheumatology via his GP to screen for early psoriatic arthritis.

2. Benign compound melanocytic naevus on the left upper back and papulopustular rosacea on the central face. The back lesion is clinically and dermoscopically benign, requiring no excision. His rosacea was likely aggravated by inappropriate topical steroid use; he will cease facial steroids immediately and commence ivermectin (Soolantra®) cream OD at night for 12 weeks. He was counselled on daily broad-spectrum SPF 50+ sunscreen use and avoidance of known vasomotor triggers including red wine and hot drinks. No specific specialist referrals are required for these two conditions, and both will be re-evaluated at his 12-week follow-up appointment.

Management Plan as Above

Commence Enstilar® foam OD to trunk and limb plaques for 4 weeks (then twice weekly), Cetraben® cream PRN as emollient and soap substitute, and Soolantra® cream OD to the face at night for 12 weeks; discontinue facial hydrocortisone immediately.

Counselled on sun protection (SPF 50+), rosacea trigger avoidance, baseline metabolic blood tests via GP, and Rheumatology referral for joint symptoms.

Additional Notes

Explained the chronic, relapsing nature of both psoriasis and rosacea, emphasizing that consistent emollient use restores the skin barrier and reduces steroid requirements. Discussed the risk of topical steroid-induced rosacea and skin thinning when applying corticosteroids to facial skin, and warned that stopping facial hydrocortisone may cause a temporary flare for 1–2 weeks before ivermectin takes effect. Highlighted the association between psoriasis, metabolic syndrome, and psoriatic arthritis.

Instructed Mr Pendelton on monthly skin self-examinations using the ABCDE criteria (Asymmetry, Border irregularity, Colour variation, Diameter > 6 mm, Evolution) and advised him to use his baseline clinical photographs for comparison.

Addressed Mr Pendelton's concern regarding the potential link between his migraine medication and his skin flare; reassured him that he should not stop propranolol abruptly, but we will liaise with his GP and neurologist if topical measures suffice or if a medication switch is warranted.

Next Steps

Mr Pendelton will collect his private prescriptions today, book baseline blood tests with his GP practice, and schedule a follow-up dermatology appointment in 12 weeks.

He was advised to contact the clinic or seek urgent medical review if he develops widespread confluent redness (erythroderma), generalized pustules, severe joint swelling, ocular grittiness or pain (ocular rosacea), or if any pigmented lesion begins to bleed, ulcerate, or change rapidly.

I recommend www.bad.org.uk and dermnetnz.org as sources of information about the matters discussed above.