Geriatric Cases with Flexural Psoriasis Over the Natal Cleft May Need Special Precaution for Decubitus Ulcer Prevention

Dear Editor, Decubitus ulcer or pressure sore is a nagging problem of elderly patients in a bedridden state.[1] Relative deficiency of subcutaneous muscles or fat makes the fragile skin over bony prominences more prone to damage by pressure and shear forces. Even a short period of bedridden status may at times be enough to initiate bedsore formation, and prevention is of paramount importance.[1,2] In patients with associated flexural psoriasis, especially over the natal cleft, inspection and prevention of the bedsores become even more important. We learned the lessons through a case, the key details of which are described below. An 80-year-old male patient presented to us with a fragility hip fracture and was planned for the fracture fixation aiming prompt recovery and weight-bearing. During the time of preanesthetic checkup and fitness process, he was advised rest and skin traction along with supportive and symptomatic treatment. The patient was otherwise healthy except chronic palmoplantar psoriasis with a history of irregular treatment. No dermatology consultation was done by the patient in the last two years. Clinically, there were evident psoriatic patches over the bilateral soles and palms [Figure 1a-c]. After two days of admission, during routine inspection for any bedsore formation, a distinct psoriatic patch was also noted in the natal cleft as flexural (or inverse) psoriasis [Figure 1d]. There was initiation of a grade 1 bedsore within that patch. Preventive strategies including regular logrolling every two hours for fifteen minutes were advised, and care of the back was instructed to attendants. Apart from that, protein-, calcium-, and Vitamin C-rich diet was encouraged. Compliant supportive treatment led to the cessation of the progression and gradual healing of the small bedsore. The hip fracture was fixed, and the patient mobilized as nonweight-bearing on walker to further decrease the chances of sore formation. After surgery, the patient was referred to dermatology for further treatment of skin lesions. Prevention, thus, resulted in avoidance of an undesirable complication of a progressive bedsore.Figure 1: The clinical image of the patient with palmoplantar psoriasis showing the plantar plaque lesion in bilateral soles (a), and both the palms (b and c). The natal cleft skin patch is well demarcated (d) and showing the beginning of a small grade 1 decubitus ulcer (denoted by arrow) within the lesion, requiring preventive strategyFlexural (or intertriginous/inverse) psoriasis is an uncommon plaque variant of psoriasis and majorly involves the areas of skin folds (such as axilla, anogenital, or inframammary) and genitals.[3] As most of these areas have moist environment, superficial erosions and lacerations are known potential complications.[4] The elderly people with natal cleft flexural lesions thus may be prone to pressure sores by the nature of the skin lesion and associated features of the senescence such as fragile and lax skin, protein deficiency, and decreased muscle and soft tissue mass over bony prominences. Besides it, these lesions are reported to be more challenging both in diagnosis and treatment.[5] The local skin, thus, should be inspected over pressure-prone areas in all geriatric patients with chronic skin disorders, and utmost care should be followed to prevent and treat decubitus ulcers promptly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.