Anca Chiriac^1,2,3, Uwe Wollina⁴ , Cristiana Voicu⁵, Adriana Diaconeasa⁶, Anca E Chiriac¹, Petru Plamadeala⁷, Raluca Miulescu⁸

1. Nicolina Medical Center, Department of Dermatology, Iasi, Romania

²    Apollonia University, Iasi, Romania

³   P. Poni Institute of Macromolecular Chemistry, Romanian Academy

⁴   Department of Dermatology & Allergology, Städtisches Klinikum Dresden, Dresden, Germany

⁵   Department of Dermatology, MedLife Medical System, Bucharest, Romania.

⁶   Dermatology Ambulatory Care Center, “Grigore Alexandrescu” Clinical Emergency Hospital for

Children, Bucharest, Romania

⁷  Department of Pathology, “Saint Mary” Emergency Children’s Hospital, Iasi, Romania

⁸  Pediatric Hospital, Ploiesti, Romania

Case report

At the beginning of spring, a young healthy man presented to consultation, for a sharply demarcated, erythematous plaque on the nasal pyramid. The lesion was completely asymptomatic; no other skin lesions were observed. Meticulous anamnesis was performed due to the anxiety of the patient and to the peculiar aspect of the skin disorder. The patient recalled the sudden appearance of the lesion after sun exposure, short daily exposures without any type of photoprotection. The skin lesion has persisted for weeks, not influenced by oral antihistamines, topical steroids, emollients, and topical tacrolimus 0.1% prescribed by his general practitioner. The patient denied any drug intake; neither past or present allergies in his or family history, and no skin disorders reported within blood relatives.

Dermatological examination confirmed a very well delineated erythematous plaque (Fig. 1), distributed in a symmetrical way, on both lateral aspects of the bony areas of the nose.

Extended lab analysis was performed but turned out to be within normal limits.

Phototesting was done, with UVB 311 nm, on the internal area of the right arm and chest, but was negative.

Allergy patch test with the European standard battery performed in the Allergy Unit was negative.

Two 4 mm punch-biopsies were done for HE examination and for immunofluorescence (IFD). IFD was negative (Fig. 2) and HE examination confirmed psoriasis (Fig. 3).

Admitting the diagnosis of psoriasis, the patient was „sent to the sun“ respecting the photo protection rules and using emollients. A two-week control proved the disappearance of the skin lesions. Close follow-up was recommended.

Fig. 2: Thickened epidermis, acanthosis, parakeratosis, granular layer present, subcorneal and intraepithelial pustules with neutrophils; inflammatory infiltrate with lymphocytes and neutrophils in the dermis (hematoxylini-eosin).

Fig. 3: Immunoflorescence – negative results.

Discussion

Facial psoriasis is a clinical form of psoriasis that has raised many debates, due to its relation with UV radiation and classification. At least three subtypes have been identified: hairline psoriasis (sometimes included in scalp psoriasis), sebo-psoriasis (misdiagnosed frequently as seborrheic dermatitis) and true facial psoriasis (lesions localized on sun exposed areas) [1]. Furthermore, a new notion has been launched, namely photosensitive psoriasis and a fourth subtype was recently described, so-called diffuse facial psoriasis [2]. Facial psoriasis is more often associated with other types of psoriasis, making the diagnosis much easier based on clinical examination.

Facial psoriasis is associated with high risk of depression and a low quality of life, especially in young patients [3]. Therapeutic measures should be individualized, topical medications (calcineurin inhibitors, steroids and vitamin D analogs) or in rare cases biologics can be used accordingly to the guidelines.

Conclusion

The particularity of the case is the description of a new subtype of facial psoriasis, with lesions localized only on the nose, initially misdiagnosed as polymorphic light eruption and, above all, the tricky role of sun exposure (from completely avoidance to therapeutic measure).

Conflict of Interest:

The authors report no conflict of interest.