Psoriasis is an immune mediated, chronic inflammatory, incurable condition of the skin that affects 2-3% of the population globally. It is associated with red, thick, scaly lesions [1], is more common in patients on higher latitudes, in Caucasians and may manifest itself with an underlying arthropathy. Psoriasis has a spectrum of presentations ranging from localized, mild disease to involvement of more than 90% of the body's surface called erythrodermic form [2]. In as many as 4% of the patients with psoriatic the first sign of disease involves changes to the nail, however, these nail changes are seen in about half patients at some point in the course of the disease. Arthropathy, specifically, Psoriatic arthritis is also seen in about 5-10% of this patient population [3]. Pathogenesis involves the secretion of cytokines such as IL-2, Interferon- γ, TNF-α by the T cells that are involved in the induction of proliferation with decreased maturation of keratinocytes [1,4,5]. The Cytokine TNF-α is one of the central immunomodulators involved in the pathogenesis of psoriasis and is also elevated in the skin of patient with psoriasis [6]. Traditional treatment involves the use of steroids, phototherapy, systemic retinoids, methotrexate and cyclosporine. In recent years the focus has shifted to TNF-α blocking agents especially in patients with psoriatic arthritis [7].

Our medical picture shows the case of a 60 year old Caucasian male with a long term history of psoriasis. He had psoriatic involvement of the skin throughout his body. Patient had no other medical problems besides hypertension and morbid obesity and was not immune compromised either. On initial interview it was apparent that this patient had depressed mood with severe anhedonia. Patient felt ostracized by his community. Because of his excess weight and body aches and pains he was not able to seek medical attention and this culminated in aggressive erythrodermic form of psoriasis as seen in the pictures above. XR images of his extremities showed minimal involvement of right hallux but were otherwise unremarkable. He was treated with steroids with appropriate analgesics and skin care. Patient condition improved after a week of treatment and was discharged from the hospital with appropriate outpatient follow-up. Both the patient and his family were educated about the disease process and their misconception about psoriasis being a contagious disease were clarified.

Our medical picture shows the exceptionally extensive cutaneous involvement of psoriatic disease process. The postural psoriasis in this patient could also have been a result of steroid use; however, this patient denied taking any medication. It also goes on to signify the social consequences of esthetically-disfiguring diseases like Psoriasis. Patient was not able to seek medical attention early on, but his social network has also ignored him because of fear of acquiring a non-contagious disease. Physicians should maintain a high level of suspicion about social consequences in patients with disfiguring medical conditions such as psoriasis and address these issues with patient and family education and appropriate follow ups.

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   Figure 1:

   Patient is a 60 year old immunocompetent gentleman with untreated cutaneous psoriasis. He presented to the emergency department with excruciating pain and inability to freely move his extremities. Radiologic findings were unremarkable.
   
   
   

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   Figure 2:

   Patient is a 60 year old immunocompetent gentleman with untreated cutaneous psoriasis. He presented to the emergency department with excruciating pain and inability to freely move his extremities. Radiologic findings were unremarkable.
   
   
   

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   Figure 3:

   Patient is a 60 year old immunocompetent gentleman with untreated cutaneous psoriasis. He presented to the emergency department with excruciating pain and inability to freely move his extremities. Radiologic findings were unremarkable.