Management of recalcitrant palmoplantar psoriasis

Abstract

Management of recalcitrant palmoplantar psoriasis and palmoplantar pustular psoriasis continues to be a challenge. Standardized therapeutic guidelines are not available due to limited data. The recalcitrant nature points to the need for systemic therapy but a trial with topical therapy is needed before planning systemic therapy. Among the topical therapies available topical steroids or combination of topical steroids with calcipotriol are the most effective. Light-based therapies are effective modalities in patients who do not respond to topical therapy. Systemic therapy is indicated in non-responders. Acitretin, methotrexate and cyclosporine are widely used. There are increasing data on the use of biologicals in non-responders to systemic immunomodulators, but the cost is a deterrent. The biologic agents include etanercept, infliximab, adalimumab, ustekinumab, secukinumab, apremilast and others. Traditional therapies such as phototherapy, acitretin or methotrexate are often preferred over newer antitumor necrosis factor (TNF) agents for patients with comorbid conditions due to the immunosuppressive effects of TNF-α inhibitors and concern about paradoxical exacerbation of disease in some patients.