To the Editor, We report the acute pain management of a patient with psoriasis who presented to the Emergency Department (ED). The patient has consented to the reporting and publication of this case report. A 40-yr-old patient presented with a four-week history of worsening long-standing psoriasis. She had been recently prescribed adalimumab and subsequently developed acute pustular eruptions on the soles of her feet and palms of her hands. As her symptoms progressively worsened, an adverse reaction to adalimumab was suspected, and the drug was discontinued. The lesions continued to worsen considerably and were associated with increasing pain and blistering. Her pain had been treated until then with doses of combination pills containing acetaminophen and codeine (325 mg and 30 mg, respectively) taken as required, with little relief. She now presented to the ED with excruciating pain and extensive lesions that prevented her from using her feet or hands (Figure). There was no other significant past medical history, chronic pain, or drug or substance abuse. The dermatology service was consulted, and palmoplantar psoriasis (PPP) was diagnosed. They advised that sterile occlusive dressings be applied to the hands and feet and prescribed oral hydromorphone 1-2 mg, as required, for the pain. The patient found that application of the dressing was unbearably painful, and the analgesics were changed to subcutaneous hydromorphone 0.5 mg every three hours. The severe pain continued, preventing her discharge from the hospital. The Acute Pain Service (APS) was then urgently consulted for advice on pain management. The APS team reviewed her history, findings, and investigations. The patient reported a pain score of 9/10 at rest and 12/10 with movement; the pain was often continuous and localized to the palms of the hands and soles of the feet. The quality of the pain was described as tingling with burning or searing, with areas of numbness and itching. She complained of worsening of the pain and altered sensation under the occlusive dressing. On examination she was alert, oriented, and hemodynamically stable but in obviously excruciating pain and severe discomfort. The preliminary diagnosis was neuropathic pain with acute hyperalgesia. The APS prescribed oral acetaminophen 650 mg q4 h, ibuprofen 400 mg q6 h, tramadol 75 mg q4 h, pregabalin 50 mg q8 h, long-acting hydromorphone 3 mg q12 h, and hydromorphone immediate release 2 mg every four hours if required. After the first dose of the drugs and observation for another four hours, the pain score had reduced to 6/10 at rest and 8/10 with activity, and its quality was described as dull aching. The patient was reassured, and it was decided that the medications would be continued for five days. She was advised to maintain a pain diary and wean herself from the hydromorphone. After one week and as the lesions healed, the pain was rated as 3/10 at rest and 5/10 with activity, and she was able to return to her previous level of activity. She took only acetaminophen, tramadol, and pregabalin for another week and was subsequently followed up in the chronic pain outpatient clinic. When followed up six weeks after her ED visit, the lesions had almost completely healed, and her pain was well controlled with the pregabalin 50 mg taken twice daily and tramadol 50 mg as required. Palmoplantar psoriasis is an uncommon form of chronic psoriasis. It affects the palms of the hands and the soles of the feet and appears as chronic flaky patches that crack and bleed. In severe cases, the condition can be disabling as N. Eipe, MD (&) J. Penning, MD The Ottawa Hospital, University of Ottawa, Ottawa, ON K1Y 4E9, Canada e-mail: neipe@toh.on.ca