Managing Chronic Rash, Nail Discoloration, and Psoriasis in a 49-Year-Old Female
At Village Dermatology in Katy and Houston, Texas, we recently evaluated a 49-year-old female who presented as a new patient with a one-year history of itchy, hardened skin on her fingers. The rash was moderate in severity and had not responded to over-the-counter treatments. A comprehensive skin, nail, and hand examination was performed, including dermatoscopic evaluation.
Clinical Findings
The patient exhibited several dermatologic conditions affecting the skin and nails:
Onychomycosis (Nail Fungus) – The right toenail showed discoloration, onycholysis (nail lifting), and subungual debris, classic findings consistent with a fungal nail infection.
Tinea Pedis (Athlete’s Foot) – Fungal infection was also noted on the feet, with scaling and itching between the toes.
Plaque Psoriasis – The patient had erythematous, well-demarcated plaques with silvery scale on both elbows, consistent with chronic plaque psoriasis.
Diagnosis
Onychomycosis (B35.1)
Tinea Pedis (B35.3)
Plaque Psoriasis (L40.0)
Treatment Plan
1. Fungal Infections (Onychomycosis and Tinea Pedis)
The patient was counseled that onychomycosis often fails to respond to topical agents and that oral antifungal therapy, while more effective, carries potential risks such as liver toxicity.
To minimize systemic risks, the patient was started on topical antifungal therapy with:
Ketoconazole 2% cream, applied twice daily to the toenail, feet, and affected hand areas for two weeks, then continued for one additional week after clearing.
She was advised that fungal infections tend to recur, particularly in humid climates such as Houston and Katy, Texas, and should report any side effects immediately.
2. Psoriasis Management
For the plaque psoriasis on her elbows, the patient was counseled on the chronic nature of psoriasis, potential triggers (such as stress, cold weather, and infections), and the importance of consistent skincare.
Treatment was initiated with:
Triamcinolone acetonide 0.1% cream, applied twice daily for 2 weeks, then as needed for flares (not exceeding 14 days per month).
Emollient moisturizers and gentle cleansing routines to support the skin barrier.
The patient was encouraged to use tar-based or zinc pyrithione shampoos, get moderate natural sunlight exposure, and maintain regular follow-ups for flare management.
Patient Counseling and Education
The patient was counseled extensively on:
The chronic and relapsing nature of psoriasis and fungal infections.
The importance of adherence to topical therapies for best outcomes.
Lifestyle factors, such as keeping feet dry, avoiding skin trauma, and reducing stress.
Follow-up was scheduled in 6 weeks to assess the response to therapy and adjust treatment as necessary.
Dermatology Insight
This case highlights how multiple overlapping dermatologic conditions—such as psoriasis and fungal infections—can complicate diagnosis and management. At Village Dermatology, our specialists in Katy and Houston take a comprehensive, individualized approach to skin and nail disorders, emphasizing both medical efficacy and patient education to prevent recurrence and improve quality of life.
