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Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 104-106

Inverse psoriasis with pityriasis amiantacea treated successfully with dapsone

1 Department of Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
2 Department of Dermatology, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India

Date of Web Publication16-Dec-2019

Correspondence Address:
Dr. Snehal Balavant Lunge
Department of Dermatology Venerology and Leprosy, JN Medical College Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdd.ijdd_26_19

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Inverse psoriasis, also known as intertriginous psoriasis, presents itself as erythematous plaques with poor or nondesquamation in skin flexion folds. Inverse psoriasis is a rare form of psoriasis associated with pityriasis amiantacea. This condition affects the intertriginous areas, making it difficult to diagnose and treat. Here, we report a case with lesions in the intertriginous area with pityriasis amiantacea in a patient of achondroplasia, who showed improvement with dapsone.

Keywords: Dapsone, inverse psoriasis, pityriasis amiantacea

How to cite this article:
Lunge SB, Swamy MB, Tatawati AS. Inverse psoriasis with pityriasis amiantacea treated successfully with dapsone. Indian J Drugs Dermatol 2019;5:104-6

How to cite this URL:
Lunge SB, Swamy MB, Tatawati AS. Inverse psoriasis with pityriasis amiantacea treated successfully with dapsone. Indian J Drugs Dermatol [serial online] 2019 [cited 2023 Feb 2];5:104-6. Available from: https://www.ijdd.in/text.asp?2019/5/2/104/272958

  Introduction Top

Psoriasis is a chronic inflammatory skin disorder characterized by scaly erythematous plaques and compromise of different body zones, usually with pruritus, and has a significant negative impact on quality of life.[1]

Psoriasis that involves the inguinal creases, axillae, submammary folds, gluteal cleft, umbilicus, and other body folds is known as flexural or inverse psoriasis.[2] Inverse psoriasis is a rare form of psoriasis that affects between 3% and 7% of the patients with psoriasis, but its actual incidence is still unknown.[1],[2] Pityriasis amiantacea is an inflammatory scaling reaction over the scalp, often without any evident cause and at any age.[3]

  Case Report Top

A 20-year-old known case of achondroplasia presented with itchy erythematous plaques over the bilateral axillary, inframammary, and gluteal skin folds with diffuse scaling over the scalp on and off for 5 years. She was born out of second-degree consanguineous marriage with no developmental delay. The patient had previously received a broad range of topical and systemic therapies that had to be discontinued due to ineffectiveness. She presented to our outpatient department with exacerbation of the symptoms in the past 2 months and also had a history of winter exacerbation. On examination, there were short limb dwarfism, frontal bossing, and lumbar lordosis, with the scalp showing diffuse, thick, yellow-colored scales with matting of hair. The lesions in the intertriginous area were moist, erythematous plaques with no scaling [Figure 1] and [Figure 2]. A differential diagnosis of seborrheic dermatitis, fungal and bacterial intertrigo, inverse psoriasis, and Hailey–Hailey disease was considered. Dermoscopy showed regularly arranged bushy red dots with thick, large, yellow-colored scales over the scalp, suggestive of psoriasis with pityriasis amiantacea, and to confirm the diagnosis, skin biopsy was done which showed features of hyperkeratosis and parakeratosis with hypogranulosis, elongated rete ridges, and suprapapillary thinning suggestive of inverse psoriasis [Figure 3]. Due to financial constraints, the patient was started on dapsone 100 mg, gentian violet over the involved areas, and topical antifungal with steroid combination was applied application only over the scalp for 1 month. After 1 month of dapsone therapy, the patient started showing improvement in scalp and flexural lesions [Figure 4] and [Figure 5]. Dapsone was continued with good remission lasting for 3 months.
Figure 1: Erythematous plaques in the inframammary area with erosions (pretreatment)

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Figure 2: Asbestos-like scales over the scalp (pretreatment)

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Figure 3: Histopathology suggestive of psoriasis

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Figure 4: Posttreatment with dapsone therapy

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Figure 5: Posttreatment picture of pityriasis amiantacea

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  Discussion Top

Inverse psoriasis may occur as a primary disorder or as a Koebner phenomenon on the top of infective or seborrheic intertriginous dermatoses.[2] However, as treatment for psoriasis vulgaris is also effective for inverse psoriasis, it seems to have a pathophysiology similar to plaque psoriasis in other skin area. The pathophysiology involves an alteration in the activation of CD4 and CD8 T-cells and proliferation and differentiation of keratinocytes. It is still incompletely understood as to why the disease commences in this particular area; the anomalous proliferation and differentiation of keratinocytes may suggest that Koebner phenomenon of constant local mechanical and chemical irritation of flexion folds possibly perpetuates the process.[4]

Inverse psoriasis usually presents itself as erythematous, well-demarcated, thin, and often symmetrical plaques in the intertriginous areas with poor or nondesquamation and lacks classical scaling of plaque psoriasis.[5] The lesions are associated with pruritus, pain, or burning sensation, causing irritation and scratching, leading to Koebner phenomenon and local lichenification.[6]

The intertriginous area are usually warmth with moisture and frequent friction leads to maceration; the area is associated with absence of scaling, leading to modified clinical appearance of psoriasis in flexion folds, compared to classical psoriasis. Hence the diagnosis becomes difficult and resistant to treatment, when compared to other skin zones.[7] Skin biopsy might be an option, which shows the same classical histopathological characteristics, and dermoscopy shows the regularly arranged homogenous red dots.

Treatment options are usually limited and often difficult to determine because of the lack of evidence-based data, high sensitivity of the area involved, and increased penetration of topical treatments in this vulnerable zone, making it a challenge for the clinician. Treatment includes the use of weaker topical corticosteroids as a first-line treatment and Vitamin D preparations or tar-based treatments as second-line options.[8] There are reported cases with dapsone as a treatment option, which has shown great effectiveness and complete remission after 4 weeks of treatment. It acts by inhibiting neutrophilic adhesion and chemotaxis and myeloperoxidase.[1]

Pityriasis amiantacea, also known as asbestos scalp, is an inflammatory scaling reaction of the scalp, occurring at any age.[9] It is characterized by large plates of scales firmly adherent to the hair and scalp. The condition usually begins during teenage years and can progress to typical psoriasis in 2%–15% of patients.[10] The essential features responsible for the asbestos-like scaling are diffuse hyperkeratosis and parakeratosis together with follicular keratosis, which surround each hair with a sheath of horn. It can also be observed as a sequel or complication of streptococcal infection, seborrheic dermatitis, atopic dermatitis, and lichen simplex. Treatment modalities mainly include topical anti-inflammatory corticosteroids and salicylic acid 5%–10%. Clobetasol propionate and ketoconazole 2% shampoo are effective.[10]

Inverse psoriasis is a rare condition with an incidence of 3%–8%. Inverse psoriasis associated with pityriasis amiantacea and achondroplasia has not been reported in literature. Inverse psoriasis because of affection in the intertriginous areas becomes difficult to treat, and we have treated it with unique low-cost drug like dapsone, which showed remarkable efficacy limiting the use of more toxic immunosuppressives.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Guglielmetti A, Conlledo R, Bedoya J, Ianiszewski F, Correa J. Inverse psoriasis involving genital skin folds: Successful therapy with dapsone. Dermatol Ther (Heidelb) 2012;2:15.  Back to cited text no. 1
Burden D, Kirbey B. Psoriasis and related disorders. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 9th ed., Vol. 2. Edinburgh: Wiley Blackwell; 2010. p. 35.11  Back to cited text no. 2
Gupta LK, Khare AK, Masatkar V, Mittal A. Pityriasis amiantacea. Indian Dermatol Online J 2014;5:S63-4.  Back to cited text no. 3
Krueger JG, Bowcock A. Psoriasis pathophysiology: Current concepts of pathogenesis. Ann Rheum Dis 2005;64 Suppl 2:ii30-6.  Back to cited text no. 4
Wang G, Li C, Gao T, Liu Y. Clinical analysis of 48 cases of inverse psoriasis: A hospital-based study. Eur J Dermatol 2005;15:176-8.  Back to cited text no. 5
Varghese M, Kindel S. Pigmentary disorders and inflammatory lesions of the external genitalia. Urol Clin North Am 1992;19:111-21.  Back to cited text no. 6
Myers WA, Gottlieb AB, Mease P. Psoriasis and psoriatic arthritis: Clinical features and disease mechanisms. Clin Dermatol 2006;24:438-47.  Back to cited text no. 7
Plewig G, Jansen T. Pityriasis amiantacea. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller SA, Leffell DJ, editors. FitzpatrickNorth Am 1992;19:111-21.ermatology. 9th ed. New York: McGraw-Hill; 2008. p. 219-24.  Back to cited text no. 8
Abdel-Hamid IA, Agha SA, Moustafa YM, El-Labban AM. Pityriasis amiantacea: A clinical and etiopathologic study of 85 patients. Int J Dermatol 2003;42:260-4.  Back to cited text no. 9
Paller AS, Mancini AJ. Papulosquamous and related disorders. In: Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 3rd ed. Philadelphia: Elsevier-Saunders; 2006. p. 85-106.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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