Rupiod psoriasis

This is rupioid psoriasis. The term is given to the thick build up of scale seen in a case like this. Usually it means the psoriasis is very active and generalised. The  build up of scale in a conical fashion can somewhat resemble an oyster or limpet shell. Rupioid like lesions can also be seen in crusted scabies and secondary syphilis so beware shaking hands. Excess alcohol consumption and heavy cigarette use both make psoriasis worse which was the case here. The heavy alcohol consumption also makes it difficult to use methotrexate or oral retinoids as his psoriasis was generalised. Topicals would never penetrate through this scale and neither would the light of phototherapy. He was put on cyclosporine 200 mgs daily with a close watch on his blood pressure and renal function. Unfortunately he also had multiple skin cancers so immunosuppression might become an issue. Biologics would be best here but he has to fail the others first!