We are used to seeing patients with psoriasis present with large scaly plaques on the elbows, knees and lower legs but sometimes patients may only have psoriasis on the hands and feet and here the diagnosis is not quite so obvious. Overweight patients, who walk around barefoot or with open backed sandals, will often develop thick keratin build up on the heels where the keratin will dry and crack giving deep painful fissures. True psoriasis is usually more extensive as in this case with forefoot involvement and on the instep extending out on to the side of the foot. Fungal infection is always a differential diagnosis but in psoriasis the web spaces between the toes are spared. Patients should use closed in shoes and can try Daivobet ointment BD for a month but many patients require an oral retinoid such as Acitretin to peel away the scale first before using the calcipotriol steroid combination or narrow band UVB to prevent it recurring.
