Psoriasis Case 4: Palmoplantar psoriasis

A 66-year-old man presented with a 15-year history of psoriasis involving the face, scalp, genitalia, and groin, with significant involvement of the palms and soles. The patient’s scalp psoriasis is well controlled using topical clobetasol solution applied twice daily on the weekends. His the face and suprapubic area psoriasis have responded well to tacrolimus ointment 0.1% twice daily and fluticasone ointment twice weekly as needed. His palms and soles, however, are completely refractory to treatment with multiple different potent topical corticosteroids under occlusion, calcipotriene ointment, and combination topical therapy also used under occlusion. A 3-month course of topical PUVA also produced only minor improvement. This patient has a history of depression treated with lithium, hyperlipidemia treated with atorvastatin, asthma, and hay fever. 

Physical examination revealed erythematous scaly and fissured hyperkeratotic psoriatic patches and plaques involving approximately 40% of both the palmar and plantar surfaces. The patient’s quality of life was significantly impacted with limitations in the use of his hands and significant pain with walking. Laboratory studies revealed a normal blood cell count, and lipid and liver panel results. Acitretin (25 mg daily) was initiated. Within 2 months, there was substantial improvement in both the palmar and plantar psoriasis, leading to a significant improvement in this patient’s quality of life Reduction of his acitretin dosage to 25 mg on alternate days was then possible and the mucocutaneous side effects associated with acitretin therapy thus diminished. An attempt to reduce his lithium dose was unsuccessful because of a worsening of his depression.

Discussion

Although palm and sole psoriasis affects a small (<5) percent of the total cutaneous surface, it is frequently debilitating, painful, and interferes with simple functions such as walking or buttoning one’s clothing. The impact of palm and sole psoriasis on quality of life is out of proportion to the small percent of BSA affected. Quality of life measurements demonstrate the emotional and physical impact of psoriasis limited to the palms and soles, justifying the use of systemic therapies in such patients.106 Thus, when intensive topical therapy under occlusion or photochemotherapy is insufficient to achieve adequate improvement and long-term control, therapy with oral or biologic medications should be given strong consideration. Both MTX and cyclosporine are effective in a significant proportion of patients, however, the potential hepatotoxicity and bone-marrow toxicity of the former and the nephrotoxicity of the latter must be considered. Palm and sole psoriasis is often responsive to oral retinoids.107 Although elevations in both triglycerides and cholesterol can be a complication of retinoid therapy, these should not necessarily be a contraindication to retinoid therapy, as elevated triglycerides can be appropriately managed with fibrates, alone or combined with statins, and elevated cholesterol can be managed with statins. Caution needs to be exercised when statins and fibrates are given simultaneously because of the risk for rhabdomyolysis. Other treatment options include targeted phototherapy (with 308-nm excimer laser or similar light sources) or PUVA, particularly soak PUVA in which patients soak their palms and soles for 15 to 30 minutes in a methoxsalen solution before UVA exposure. Topical PUVA usually requires treatments two or three times per week for several months for adequate clearing and maintenance of control of palmoplantar psoriasis. As discussed in our prior case, oral PUVA has been associated with the development of cutaneous malignancies after long-term treatment. Cutaneous malignancy on the palms or soles after topical PUVA therapy is, however, very rare. Using oral acitretin in combination with topical PUVA also reduces the number of treatments necessary for clearing106,107 and potentially decreases the risk of development of skin malignancies associated with PUVA therapy.54

Navigate section 6 of the psoriasis guideline: Case-based review

Citation note

Menter A, Korman NJ, Elmets CA,Feldman SR, Gelfand JM, Gordon KB, Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74. 



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