Case Number : Case 4052 - 02 August 2022 Posted By: Uma Sundram

Multiple parakeratotic foci alternating with orthokeratotic foci with neutrophils and neutrophilic spongiform pustules r suggestive of palmoplantar psoriasis.. 

Multilayered parakeratosis and massive thickening of stratum corneum suggest that it could be a thick lesion of rupioid psoriasis or keratoderma blenorrhagica which occurs in reactive arthritis. Vertically alternating orthokeratosis and parakeratosis suggest intermittent activity of the disease which makes Bazex syndrome (acrokeratosis paraneoplastica) unlikely. 

22 hours ago, Anil Patki said:

Multilayered parakeratosis and massive thickening of stratum corneum suggest that it could be a thick lesion of rupioid psoriasis or keratoderma blenorrhagica which occurs in reactive arthritis. Vertically alternating orthokeratosis and parakeratosis suggest intermittent activity of the disease which makes Bazex syndrome (acrokeratosis paraneoplastica) unlikely. 

Agree with psoriasis and explanation for intermittent activity. 

Agree with above. Just learnt about the vertically oriented para/ortokeratosis consistent with Bazex syndrome. Thanks Anil. 

3 hours ago, vincenzo said:

Agree with above. Just learnt about the vertically oriented para/ortokeratosis consistent with Bazex syndrome. Thanks Anil. 

Vertically oriented para/ortho consistent with palmoplantar psoriasis and against Basex syndrome I think.. Basex syndrome characterised by necrotic keratinocytes.

Ah OK! I read too quickly, sorry. Thanks for these interesting points. 

Lesion showing thick hyperkeratosis with neutrophillic collection inbetween orthokeratosis above and parakeratosis below. I believe this is the "sandwich sign" of Dermatophytosis as some structures in image3 remind me of hyphae. Also, normal granular layer if not focal areas of Hypergranulosis goes against psoriasis. Bazex typically shows interface pattern with keratinocyte necrosis, which is absent here. Based on clinical clues of lesional presence on dorsum as well as ventral aspect of foot alongwith nail dystrophy (possibly due to tinea ungium) I would like a PAS stain or KOH mount for confirmation of Tinea.

Pas is negative. We suspected palmoplantar pustulosis as patient also had lesions on her hands. Tinea cannot be entirely excluded but it is unlikely. We still included pustular psoriasis in the ddx. Agree Bazex is ruled out; spongiform pustules would be unusual in Bazex.