PUSHPAGIRI COLLEGE OF PHARMACY 1

CASE PRESENTATION

NAME : AKSHAYA.S
ROLL NO: 2

PUSHPAGIRI COLLEGE OF PHARMACY 2

A 54 YR OLD MALE PATIENT WAS ADMITTED WITH MULTIPLE

REDDISH RAISED LESIONS WITH SCALING ALMOST ALL OVER

THE BODY AND SCALP( SINCE 4 MONTHS ) ON 16TH JANUARY

2015.THE SYMPTOMS WAS STARTED 1 YEAR BACK AS ITCHING

OF RIGHT HAND WHICH SLOWLY PROGRESSED TO INVOLVE

LEFT HAND AND CHEST.

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 DEMOGRAPHIC DETAILS

 NAME: ANTAPPAN  DOA: 16/1/15

 AGE: 54  DOD: 1/2/15
 SEX: Female  DEPARTMENT: DEPARTMENT OF DERMATOLOGY

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 SUBJECTIVE

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  PRESENTING COMPLAINTS

 Patient was presented with multiple reddish raised

lesions with scaling almost all over the body and scalp
since 4 months.
 Pain over finger joints.

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 PAST MEDICAL HISTORY

 The symptoms was started 1 year back as itching of right

hand which slowly progressed to involve left hand and chest.
Later papular lesions developed over both legs with
associated itching.
 H/o Pulmonary tuberculosis ,13 years back and took
treatment for 6 months.
 H/o Typhoid 4yrs back.

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  PAST MEDICATION HISTORY

 He started MTX 5 mg per week,Propyl salicylic acid and

other supportive medicines. Lesions start subsiding but
developed peeling of lips and oral cavity. For 6 months
he took MTX on and off and totally discontinued after 2
months.

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  PERSONAL HISTORY

 He was a smoker .Stopped 3 months back.

 He was a chronic alcoholic. Stopped 3 years back.

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 OBJECTIVE

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 DERMATOLOGIC EXAMINATION

 Multiple well defined erythematous plaques of varying sizes

distributed over both upper limb, extensor aspect of lower
limb, back, buttocks, a few over chest, abdomen, dorsum of
hands and feet involving nail fold.
Scales are dry, white and micaceous.
Dry white scales over both external ear.

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  Subungual hyperkeratosis present over both toes , few
fingers along with brownish discolouration.
Scalp: multiple well defined erythematous plaques, dry,
white scales present.
Palms: erythematous plaques with scales present.
Nail : well defined erythematous plaques with present
over nail fold.
Oral cavity: white coating of tongue , violaceous plaque
in inner aspect of cheek.
Perianal area: fissure present with whitish discharge.

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 SYSTEMIC EXAMINATION

 P/A : Soft, non tender , no organomegaly , bowel sounds (+)

 RS : B/L NVBS, B/L air entry equal
 CVS : S1S2 heard, normal
 CNS: conscious , oriented, HMF normaL
 INVESTIGATIONS

 Mild spleenomegaly , B/L renal cortical cyst

 Rectal mucosal biopsy: colonic mucosal tissue with edema
and congestion and mild nonspecific colitis

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 Skin biopsy :
Epidermis shows hyperkeratosis, parakeratosis , regular acanthosis.
Papillary dermis shows dilated blood vessels.
Dermis: scattery inflammatory cell infiltration. A small munro
abcess also seen.
Consistent with psoriasis.
 RETROVIRAL Ag and Ab: Positive
 VDRL TEST : Non reactive
 TPHA: Non reactive
 PERIPHERAL BLOOD SMEAR: Normocytic, normochromic anemia
and mild eosinophilia and thrombocytopenia.

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  LAB RESULTS
PARAMETER VALUE INFERENCE INTERPRETATION
PULSE 76/min 72/min NORMAL
BP 130/80mmHg 120/80 mmHg NORMAL
Hb gm% 9.4gm% 13-18gm% LOW
PCV 27.6% 40-54% VERY LOW
TOTAL WBC 8000 cu.mm 4000-11000 NORMAL
cu.mm
DC POLY 61% 40-75% NORMAL

DC LYMPH 20% 20-50% NORMAL

DC EOS 9% 1-6% HIGH

DC MONO 10% 2-10% NORMAL
ESR 60mm/hr 0-15 HIGH
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 LAB RESULTS(CONTD……)

PARAMETER VALUE INFERENCE INTERPRETATION

UREA 17mg/dl 20-40mg/dl SLIGHTLY LOW

CREATININE 0.74mg/dl 0.5-1.4mg% NORMAL

CALCIUM 8.4mg/dl 8.4-10.6mg/dl NORMAL

RBS 106mg/dl 70-140mg/dl NORMAL

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 ASSESSMENT

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 DIAGNOSIS

 PSORIASIS WITH ACUTE EXACERBATION

 ARTHROPATHY

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 PSORIASIS

Psoriasis is a common skin condition

that changes the life cycle of skin cells.
Psoriasis causes cells to build up
rapidly on the surface of the skin. The
extra skin cells form thick, silvery scales
and itchy, dry, red patches that are
sometimes painful.

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 ETIOLOGY

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 SIGNS AND SYMPTOMS

 Red patches of skin covered with silvery scales

 Small scaling spots (commonly seen in children)
 Dry, cracked skin that may bleed
 Itching, burning or soreness
 Thickened, pitted or ridged nails
 Swollen and stiff joints

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 TYPES OF PSORIASIS

 Plaque psoriasis: The most common form, plaque

psoriasis causes dry, raised, red skin lesions (plaques)
covered with silvery scales. Can occur anywhere on the
body, including genitals and the soft tissue inside your
mouth.
 Nail psoriasis. Psoriasis can affect fingernails and
toenails, causing pitting, abnormal nail growth and
discoloration. Psoriatic nails may become loose and
separate from the nail bed (oncholysis)

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  Scalp psoriasis: Psoriasis on the scalp appears as
red, itchy areas with silvery-white scales. The red
or scaly areas often extend beyond the hairline.
 Guttate psoriasis: This primarily affects young
adults and children. It's marked by small, water-
drop-shaped sores on arms, legs and scalp. The
sores are covered by a fine scale and aren't as thick
as typical plaques are.

 Inverse psoriasis: Mainly affecting the skin in the

armpits, in the groin, under the breasts and around
the genitals, inverse psoriasis causes smooth
patches of red, inflamed skin. It's worsened by
friction and sweating

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 Pustular psoriasis: Uncommon form of psoriasis. It
can occur in widespread patches or in smaller areas
on hands, feet or fingertips. It generally develops
quickly, with pus-filled blisters . The blisters may
come and go frequently.
 Erythrodermic psoriasis: The least common type of
psoriasis, erythrodermic psoriasis can cover the
entire body with a red, peeling rash that can itch or
burn intensely.
 Psoriatic arthritis: In addition to inflamed, scaly skin,
psoriatic arthritis causes pitted, discolored nails and
the swollen, painful joints that are typical of arthritis.
Psoriatic arthritis can affect any joint.

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PUSHPAGIRI COLLEGE OF PHARMACY 25
TREATMENT CHART
1 2 3 4 5 6 7 8 9 1 1 1 1 1 1
BRAND NAME DOSE FREQUENCY 0 1 2 3 4 5

T.CEFOLAC XL 200mg 1-0-1    

T.ETROBAX 90mg 1-0-1          

T.PANTOP 40mg 1-0-0               

T.ATARAX 25mg 1 HS               

T.ZYRTEC 10mg 1-0-0              

T.SHELCAL CT 500mg 1 -0-0             

T.BENDEX 400mg 1 HS           

T RIBOFLAVIN 10mg 1 DAILY           

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 1 2 3 4 5 6 7 8 9 1 1 1 1 1 1
BRAND NAME DOSE FREQUENCY 0 1 2 3 4 5

C.BECOZINC 1 DAILY           

T.BETENESOL 0.5mg TDS(gargle)          

C.DOXY-1 100mg 1-0-1         

C.MAXEPA 1-0-1        

T.ULTRACET 1-0-1        

T. AF 150mg 1 hs      

T SEPTRAN DS 1-0-1      

T.MONTEK LC 0-0-1      

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 OTHER THERAPY:

 TENOVATE CREAM FOR LA

 DERMASOFT LOTION FOR LA
 VITAFIBER 2 TSP IN 1 GLASS
WATER FOR ALL THE DAYS
 NESIL -3 FOR LA
 SCALP SHAMPOO FOR SCALP
 NB UVB 11-0-11 REGIMEN
 CONDY’S BATH

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BRAND GENERIC INDICATION ADR INTERACTION
NAME NAME / CLASS

T.ATARAX HYDROXYZINE ANTIHISTAM DROWSINESS,HEA INCREASED

INE DACHE,XEROSTO DROWSINESS
MIA,TREMOR,SEIZ WITH CETRIZINE
URE AND TRAMADOL

T.ZYRTEC CETIRIZINE ANTIHISTAM SOMNOLENCE,DR WITH

HYDROCHLORI INES Y HYDROXYZINE,SID
DE MOUTH,DIZZINES E EFFECTS SUCH
S AS DIZZINESS OR
DROWSINESS MAY
INCREASE
T.SHELCAL CT ELEMENTAL VIT D AND
CALCIUM+CAL ANALOGUES
CITRIOL

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 DISCUSSION ON THERAPY
BRAND NAME GENERIC NAME INDICATION/ ADR INTERACTION
CLASS

T.CEFOLAC XL CEFIXIME+CLOXA SUSCEPTIBLE THROMBOCYTOPENIA, -

CILLIN INFECTIONS EOSINOPHILA,DIARRH
EA,VOMITING

T.ETROBAX ETORICOXIB NSAIDS(RHEMATOID ISCHAEMIC CARDIAC -

ARTHRITIS) EVENTS,
HYPERSENSITIVITY
REACTIONS,PHOTOSE
NSITIVITY,MOUTH
ULCERS

T.PANTOP PANTOPRAZOLE ANTACID PRURITIS,SKIN -

RASHES,DIARRHEA,DIZ
ZINESS

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 BRAND GENERIC NAME INDICATION/ ADR INTERACTION
NAME CLASS

C.MAXEPA EPA,DHA SUPPLEMENTS&ADJ - -

UVANTS

T.ULTRACET TRAMADOL+PARACE ANALGESIC NAUSEA, INCREASED

TAMOL VOMITING,DIZINES DROWSINESS
S, AND DIZZINESS
FLATULENCE.SEVER WITH
E ANAPHYLACIC HYDROXYZINE
REACTION

T. AF FLUCONAZOLE ANTIFUNGAL HEADACHE, -

RASHES,
EXFOLIATIVE
DERMATITIS
T SEPTRAN SULFAMETHOXAZOL ANTIBIOTICS RENAL -
DS E+TRIMETHOPRIM FAILURE,ANOREXIA,
STEVEN JOHNSON
SYNDROME,SKIN
RASHES

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BRAND NAME GENERIC NAME INDICATION/ ADR INTERACTION
CLASS
BENDEX ALBENDAZOLE ANTHELMINTHI GI DISCOMFORT, -
CS HEADACHE, NAUSEA

T RIBOFLAVIN VIT B2 VITAMIN - -

SUPPLEMENT

C.BECOZINC ZINC ZINC AND - -

MONOHYDRATE,VIT VITAMIN
B1,B2,B6,B12,NIACINA SUPPLEMENT
MIDE,FOLIC ACID

T.BETENESOL BETAMETHASONE CORTICOSTEROI MUSCLE -

DS WASTING,WEAKNESS,
OSTEOPOROSIS, GI
DISTURBANCES AND
BLEEDING

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 BRAND GENERIC NAME INDICATION/ ADR INTERACTI
NAME CLASS ON
DERMASOFT EMOLIENT MILD
LOTION ITCHING,BURNING,STIN
GING

TENOVATE CLOBETASOL CORTICOSTEROID PERIORALDERMATITIS,

CREAM DERMAL AND
EPIDERMAL ATROPHY

NESIL-3 SALICYLIC ACID TOPICAL IRRITATION,SENSITIVITY,

ANTIFECTIVE EXCESSIVE DRYING

CONDYS BATH POTASSIUM TOPICAL -

PERMANGANATE ANTIINFECTIVES

T.MONTEK LC MONTELUKAST+LE ANTIHISTAMINES DIZINESS,FATIGUE,RASH

VOCETRIZINE ES,DENTAL
PAIN,BLEEDING
TENDANCY

C.DOXY-1 DOXYCYCLINE TETRACYCLINE STAINING OF

ANTIBIOTIC TEETH,SUPER
INFECTION,BLEEDING
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 DISCHARGE MEDICATION
o DERMASOFT LOTION FO LA
o T.ATARAX, 25mg 1 HS
o TENOVATE CREAM FOR LA
o T.ZYRTEC 10mg 1-0-0
o T SHELCAL CT 10 mg 1-0-0
o VITAFIBER 2 TSP BD IN 1 GLASS WATER
o CAP. BECOZINC 1 OD
o SCALP SHAMPOO
o T.MAXEPA 1-0-1
o T.ULTRACET 1 SOS
o T.RIBOFLAVIN 1 OD
o T SEPTRAN DS 1-0-1
o MONTEK LC 0-0-1
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 PLAN ON DISCHARGE

 Patient was referred to ART ( Anti Retroviral Therapy) centre for

ART

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 PLAN

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 PATIENT COUNSELLING

 The prescribed drug regimen should properly followed.

 Albendazole drug should be taken with food.
 Moisturizers should be used regularly. Dry skin makes the irritation
and itchiness worse.
 Pat yourself dry and put the creams on right after bathing to seal in
water.
 Don’t use hot water, which can irritate. Use lukewarm water instead
for bath.

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  Don’t towel off by rubbing. Pat yourself dry and then apply
cream.
 Smoking and alcoholism can aggravate the disease. The
patient should not use this again.
 Since the disease is not curable psychological support can be
given to the patient. The patient can join to certain
supporting groups for this.
 HIV infection can make the disease more worse. So
medications should be followed properly.

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 PHARMACIST INTERVENTION

 Using cetirizine together with hydroxyzine and tramadol, the patient

may feel extreme dizziness.
 Albendazole is recommended to administer along with food.

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 REFERENCES

 CIMS
 LEXICOMP’S DRUG INFORMATION HANDBOOK
 www.drugs.com
 www.webmed.com
 www.medscape.com

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