A Complex Patient

The patient is a 61 year-old woman with long-standing insulin-dependent diabetes, rheumatoid arthritis and insulin-dependent diabetes. Her rheumatologist has treated her with methotrexate which she stopped b/c of side-effects. She has also had side-effects (mostly urticaria) with Humira and Remicaide. She was referred for her psoriasis by another dermatologist. Her meds include insulin and prednisone 10 mg per day.

O/E: The patient appears older than her stated age. She appears to have mild facial lipoatrophy. The stigmata of RA is seen in her hands. Her psoriasis is limited to plaques on her back.




Discussion: Given her infirmities and reaction to standard RA and psoriasis meds, I elected to start her on narrow band UVB and clobetasol ointment 0.05% applied after a bath (Soak and Smear protocol).

Questions: Is this real facial lipoatrophy? Is it related to the DM or RA. The patient has not risk factors for HIV or history of abnormal hemograms to suggest immunodeficiency.