A 29-year-old prisoner with a history of plaque psoriasis complained of herpes zoster (shingles) of 2 months' duration. He had experienced a sudden onset of right-sided chest and back pain that evolved into a red rash with blisters. The pain resolved, but the rash persisted (A, B). A review of systems was otherwise negative. The patient had indeed suffered an initial episode of herpes zoster, though it is uncommon for its cutaneous manifestations to last more than 2 to 3 weeks in non-elderly, immunocompetent patients. The lesions that persisted were psoriasis indicative of Koebner phenomenon. At the time, the patient's psoriasis involved approximately 30% of his body surface area and was demonstrating little response to topical therapy. Based on this indication, as well as the patient's incarceration, he was treated with systemic methotrexate therapy. The patient experienced improved control of his disease over the following months.
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