LAUSR

© BMJ Publishing Group Limited 2023. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A woman in her late 50s with chronic kidney disease stage V, diabetes mellitus type II, chronic obstructive pulmonary disease (COPD), coronary artery disease and heavy tobacco use presented with altered mental status, hyperkalaemia and mixed respiratory and metabolic acidosis. Physical examination revealed numerous thick hyperkeratotic plaques measuring 10–20 mm located on the forearms and shins with firmly adherent scales over fingers and toes bilaterally with pinpoint capillary bleeding indicative of positive Auspitz sign, in addition to perioral scaly erythematous rash (figures 1 and 2). Her skin lesions initially started 9 months prior to her current presentation. She was treated with triamcinolone 0.1% cream two times per day, which was changed to clobetasol ointment 0.05% two times per day with no significant response. Her altered mental status was attributed to an acute exacerbation of COPD. She was started on intravenous methylprednisolone three times a day as part of the management of COPD exacerbation and hydrocortisone 1% ointment two times per day for dermatitis with no significant improvement of her skin lesions. Histopathological examination of her skin biopsies demonstrated an irregularly acanthotic epidermis with slight spongiosis, psoriasiform epidermal hyperplasia, perivascular lymphocytic infiltration, hyperkeratosis and confluent parakeratosis with neutrophilic collections (figures 3 and 4). A preliminary diagnosis of rupioid psoriasis versus acrokeratosis paraneoplastica was made. There was a concern for a potential underlying internal malignancy given the classification of acrokeratosis paraneoplastica a paraneoplastic dermatosis. She had a family history of type 2 diabetes, breast and colon cancer, asthma, COPD and coronary arterial disease. Therefore, CT of the chest and abdomen and esophagogastroduodenoscopy was performed with negative findings for any underlying neoplasia. A final diagnosis of rupioid psoriasis was made and due to the lack of response to topical and systemic steroids, she was started on 0.1% tacrolimus cream applied to bilateral upper and lower extremities two times per day with significant improvement of her skin lesions within 2 days. Unfortunately, after hospital discharge, she was lost to followup.