A 26-year-old HLA-B27 positive man presents with a 4-week history of asymmetric oligoarthritis, conjunctivitis, dysuria with sterile urethral discharge, and hyperkeratotic erythematous scaly pustular plaques on the palms and soles with thick keratotic margins resembling shells — consistent with keratoderma blennorrhagicum secondary to reactive arthritis triggered by prior Shigella infection. The skin biopsy shows parakeratosis, Kogoj pustules, and dermal lymphocytic infiltrate. Which of the following represents the **first-line topical management** for the palmoplantar keratodermic lesions marked **A** in the diagram?
A. Methotrexate 15 mg weekly with folic acid supplementation
B. Doxycycline monotherapy targeting residual Chlamydia infection
C. High-potency topical corticosteroids (clobetasol propionate 0.05%) under occlusion combined with keratolytics
D. Systemic acitretin monotherapy for 8–12 weeks
Explanation
Why high-potency topical corticosteroids under occlusion is correct
According to Rook's Textbook of Dermatology, 9th edition, the first-line therapy for palmoplantar keratoderma blennorrhagicum in reactive arthritis is high-potency topical corticosteroids (clobetasol propionate 0.05%) applied under occlusion, combined with topical keratolytics such as salicylic acid or urea to reduce the thick hyperkeratosis. This stepwise approach addresses both the inflammatory pustular component and the keratotic burden, and is initiated before systemic agents are considered.
Why each distractor is wrong
Systemic acitretin monotherapy: Systemic retinoids are reserved for severe refractory keratoderma that has failed topical therapy and NSAIDs, not as first-line treatment. Acitretin carries teratogenic risk and requires careful monitoring.
Methotrexate 15 mg weekly: Methotrexate is a DMARD used for refractory chronic reactive arthritis and severe mucocutaneous disease, not as initial topical management of keratoderma. It is a second- or third-line systemic agent.
Doxycycline monotherapy: While doxycycline is indicated for oral antibiotic therapy targeting persistent Chlamydia infection in reactive arthritis, it does not directly treat the cutaneous keratodermic lesions and is not topical management.
High-YieldNEET PG
In reactive arthritis keratoderma blennorrhagicum, always start with high-potency topical corticosteroids under occlusion + keratolytics; reserve systemic retinoids, DMARDs, and TNF-alpha inhibitors for refractory disease.
Rook's Textbook of Dermatology, 9th ed., Ch. on Reactive Arthritis
Practice similar questions
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.
