PMC6287317_01
A-D, Cutaneous manifestations at baseline, with palmoplantar hyperkeratosis and fissuring at the fingertips and plantar surface. E, Response to anti-TNF therapy (adalimumab 40 mg every two weeks) at two months. F, Response to therapy for skin involvement at the feet was delayed and required an increased dosing regimen (adalimumab 40 mg weekly; photo taken three months following dosing regimen increase).
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Fissuring was seen at the fingertips and the plantar surface of the feet (Figure 1(A) to (D)) without associated pustulosis. After four injections of adalimumab, the patient experienced significant improvement in cutaneous manifestations at the palms (Figure 1(E)). Clinical involvement at the feet proved more recalcitrant and required an increase in the dosage of the adalimumab to weekly, resulting in clinical improvement (Figure 1(F)).
Radiographic findings of axial SpA. Plain radiographs demonstrate bilateral sacroiliac joint fusion as well as thin (marginal), syndesmophyte formation throughout the lumbar spine (arrows) resulting in the formation of the "bamboo spine."
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Given the patient's history of uveitis (which upon review of the chart was recurrent and associated with HLA-B27 positivity), the hyperkeratotic and plaque-like appearance of his lesions, and the concern for possible axial spine disease based on examination, formal radiographs were obtained (Figure 2) and a referral to rheumatology was initiated.