Occurrence and challenges in the management of severe chronic plaque type psoriasis in a limited resourced setting: a case report

Plaque-type psoriasis is a major dermatosis with significant effects on quality of life. Case complexity is often high in low-resourced settings such as in Africa where the incidence has been on the rise. Despite major advancements and newer therapeutic modalities over the last decade, an insight into the real-life, day to day challenges in low resourced settings reveal an interplay between the difficulty in obtaining these drugs and use of alternative traditional indigenous agents. We report the case of a 50 year old immunocompetent male who presented with chronic and extensive well demarcated plaques covered with silver-white scales occupying about 61% of his body surface area. Patient was however lost to follow up for about 8 months during which time, the lesions responded to some unknown homemade indigenous medications which was preferred to a systemic medication. Paramount importance on proper counselling and the need to retain patients in care is warranted by physicians and allied health personnel. Also, incentives aimed at subsidizing the newer systemic agents for patients in low resourced cohorts will go a long way to combat this multi-faceted disorder which is often unrecognized and under diagnosed.


Introduction
Psoriasis is an immune-mediated, complex, chronic, noncontagious multisystem inflammatory disorder that affects approximately 2-3 % of people world. The disease is less common in the tropics and in dark skinned persons with an estimated prevalence of 1.3% in African Americans compared with the 2.5% in whites [1]. There is a huge genetic predisposition for the illness which affects patients far beyond the skin; with joint involvement in about 30% of cases [2]. No specific area limitation is ascribed to disease manifestation and multiple types have been identified, with plaque-type (discoid) psoriasis being the commonest. These plaques appear as well-demarcated, focal, raised edematous lesions covered with silver-white micaceous scales.
Diagnosis is mainly clinical, however, a dermatologic biopsy is warranted in those cases where recognition remains a puzzle.
Treatment modalities are chosen based on disease severity, relevant comorbidities, patient preference (cost and convenience), efficacy and evaluation of individual patient response [3]. In its severe form, psoriasis can have a remarkable socioeconomic influence as it impacts the affected individual and society at different levels. Various objective and subjective assessments for severity of psoriasis have been discussed; generally relying on scoring systems for which the Psoriasis Area Severity Index score (PASI) is the most adequate available tool [4]. Severe variants require treatment with systemic agents either as monotherapy or combination of multiple agents whose long term safety and laboratory monitoring have to be defined. Recently developed and upcoming biologics offer new therapeutic approaches but the difficulty in reliably obtaining, storing and using them coupled with their high costs is a dilemma for patients with lower socioeconomic status [5]. In low and middle income countries (LMIC), case complexity is often high and available resources from the individual to societal perspective (particularly primary health care) are often suboptimal. We describe herein the case of a 50 year old male in a low-resourced setting with severe chronic plaque-type psoriasis, lost to follow-up in whom management was challenging and difficult; our key objective being to emphasize on the complexity of this multisystem disease in a tropical setting and the need to retain patients in care.

Patient and observation
A 50 year old male cattle herdsman with no known personal or family Furthermore the negative blood tests and the cutaneous histology together ruled out drug induced, atopic, infectious or seborrheic erythroderma. Also, obtaining blood for flow cytometry and Sézary cell count (to assess the potential of blood involvement in cutaneous T cell lymphoma or Sézary syndrome) would've been useful but the absence of atypical lymphocytes on the biopsy specimen made the primary clue for the diagnosis of cutaneous T cell lymphoma unlikely. Pityriasis rubra piliaris is a close differential diagnosis which not uncommonly presents as a diffuse erythroderma with psoriatic-like scales. However, the lack of some clinical distinctive features, such as islands of pale skin (skip lesions), orange-red scaling erythema, and palmoplantar yellowish keratoderma makes psoriasis the more likely diagnosis in our patient. Ocular manifestations are not uncommon in psoriasis with blepharitis being the most common finding. Other manifestations include ectropion and trichiasis, conjunctivitis and conjunctival hyperemia, corneal dryness/melt [6]. Conjunctivitis and conjunctival hyperemia were the identified features in the patient. Once diagnosis is made, treatment is based on the severity of the skin condition which is defined by various objective and subjective assessments for which the PASI is the most adequate instrument available to evaluate severity in plaque type psoriasis [4].
Also there has been a general consensus that involvement of the face, palms/soles or disease that is disabling should be considered as severe. Our patient had a PASI score of 13.6 and 61% BSA affected which defines severe psoriasis, qualifying him for treatment with systemic agents. Traditional systemic agents like retinoids, antimetabolites (methotrexate), immunomodulators (cyclosporine) and TNF inhibitors (etanercept) all improve the clinical symptoms in psoriasis by acting on the main pathways of the psoriatic lesion which can either be used alone or in combination (daily sun exposure, sea bathing, topical moisturizers and relaxation) but concerns lie with their long term safety and efficacy [7]. Biologics (like ustekinumab, secukinumab), are the most recent and effective medications for psoriasis but present a big challenge to patients because aside from the difficulty in reliably obtaining, storing and using them, they are very expensive (30,000-80,000 USD/year) and most insurance companies tend not to approved [5]. In sub-Saharan Africa where about 47% of the population live on less than 0.25 USD/day [8] and where cost of treatment is essentially out of pocket, it represents a significant problem for both physicians and patients. The folic acid antagonist methotrexate (MTX) which is relatively cheaper than at least some of the biologic agents was readily available in our context.
It is also effective for the treatment of psoriatic arthritis and nail arthritis. Initial thoughts on the mechanism of action centered around the antiproliferative effects on DNA synthesis in epidermal cells; subsequent evidence supports the concept that it is the immunosuppressive effects of methotrexate on T-cells that controls psoriasis [9]. It was started at an initial weekly dose of 10mg together with adjunctive therapy (phototherapy, sea bathing). Folic acid 1mg daily was also given to protect against common side effects like stomatitis. The patient however deferred medical treatment and was lost to follow-up, preferring some homemade indigenous traditional medication whose beneficial effects resulted in resolution of eruptions about 8 months later. No information about the drug name nor active ingredient could be got. This wasn't entirely surprising as it is well established that some indigenous methods like wet cupping Hijamah and some African traditional plants like Kigelia Africana have been shown to be beneficial in the treatment of psoriasis.

Conclusion
In our setting where physician inertia and lack of relatively well- patients in care is absolute. A recent study analyzing skin diseases among elderly patients attending a dermatology unit in Tanzania revealed an overall prevalence of psoriasis to be 7.7%, which is relatively higher than the worldwide prevalence of 2.2-3.9% [10]. This could serve as a wakeup call to raise awareness of the complexity of this multifaceted disease especially as most of the milder cases could go undiagnosed or discovered incidentally. The need for early diagnosis, appropriate referral and comprehensive state-of-the-art approach in the management of patients with psoriasis cannot be overemphasized.

Competing interests
The authors declare no competing interests.

Authors' contributions
Calypse Asangbe Ngwasiri managed the patient, wrote the manuscript and did the review of literature; Ngo-Mbaki Charmaine Kwangsa managed the patient; Martin Hongieh Abanda: proofreading; Leopold Ndemnge Aminde: critical revision to the manuscript. All authors have read and approved the final copy of this manuscript. Table and figures   Table 1: psoriasis area and severity index (PASI)