PMC8424462_01
palmar psoriasis before (1a) and after (1b) treatment with secukinumab over 4 months.. Manifestations of HS localized in the inguinofemoral region before (1c) and after (1d) treatment. Pyoderma gangrenosum two months after adalimumab discontinuation (1e), clinical image 4 months after secukinumab treatment (1f) and post-prednisolone i.v pulse therapy (1g). Plantar pustulosis before (1h) and after secukinumab treatment (1i).
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One month after discontinuation of adalimumab, the patient developed confluent erythematous pustules on the palms ( Figure 1a) and soles ( Figure 1h) with psoriasis-like scaling of the lesions followed by intermittent shoulders and knee pain and swelling. Two months after therapy discontinuation, single, disseminated, painful pustules appeared on both thighs and lower legs ( Figure 1e), which progressed to painful ulcers ( Figure 1f) with elevated violaceous margins. Four months later, the patient demonstrated a significant remission of her HS lesions ( Figure 1d) (DeltaIHS4 9 and DeltaDLQI 11), joint pains and pustular psoriasis ( Figure 1b, Figure 1i), with only moderate improvement of her PG lesions. The treatment was followed by PG improvement ( Figure 1g).
Bone scan revealing a "bull's head" sign-like radiopharmaceutical accumulation of the costoclavicular region (2a, red arrow) and of the wrist joints (2b).. (2c): histopathologic evaluation of palmar pustular eruptions revealed characteristic microabscesses of subcorneal neutrophilic accumulation. (2d): Histology of the lower-leg ulcerations demonstrated diffuse neutrophilic inflammation as a hallmark of pyoderma gangrenosum.
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We performed a bone scan, which showed intense radiopharmaceutical accumulation of the left knee ( Figure 2a) and the wrist joints showed signs of arthritis and synovitis ( Figure 2b), with no typical pattern of psoriatic arthritis. The pattern of the bull's head sign ( Figure 2a, red arrow) was detected, usually identified as a pathognomonic sign of SAPHO syndrome.  The patient did not admit having a pain or recurrent swelling of the costoclavicular region or back pains. Dermatohistology of the palmoplantar lesions revealed characteristic neutrophilic abscesses, compatible with pustular psoriasis ( Figure 2c). The histopathological evaluation confirmed a PG ( Figure 2d).