Treatment options for palmar psoriasis
Jeffrey M. Weinberg, MD
January 29, 2010
Learning Objective:
Upon completion of this activity, participants should be able to:
- Describe the current standard of treatment for moderate to severe psoriasis, including the use of traditional and biologic systemic agents
- Recognize the clinical effect of psoriasis on the development of cardiovascular comorbidities
Question:
What is the recommended treatment for severe disabling palmar psoriasis (differential diagnosis includes hand eczema) in a patient with coronary artery disease, obesity, and recent placement of a defibrillator? Answer:
Palmar psoriasis can be severely disabling, affecting both personal and professional activities. There are three major options for patients such as these: topical therapy, phototherapy/laser, and systemic therapy. In the most severe cases, topical therapy is often unsatisfactory. However, I have had some success with calcipotriene 0.005% and betamethasone dipropionate 0.064% ointment.
If topical therapies are unsatisfactory, I generally recommend the use of the excimer laser.1,2 The treatment course is twice weekly for 6–10 weeks. I have had some success with this therapy in both plaque and pustular disease of the palms and soles. The excimer laser is quite effective and also has an excellent safety profile. Of note, I have been treating one patient with palmoplantar psoriasis who discontinued efalizumab after it was withdrawn form the market. She decided to avoid further systemic therapy, and we are keeping her disease under control with weekly excimer treatments. If the excimer laser is not available to your patient, then either topical PUVA or hand narrowband UVB would be an option.
Finally systemic therapy is an option. Acitretin has been used for many years for this indication. Efalizumab was a very good option, and was very well studied in the treatment of palmoplantar psoriasis.3 Since its voluntary withdrawal earlier in the year,4,5 many patients successfully controlled on the drug have been in need of new therapies. Several other biologics are options. I have observed success with etanercept and adalimumab in some patients. Alefacept has also been noted to have success in some cases.6 The recent introduction of ustekinumab may provide us with another option.
References - Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. 2009;
- Gattu S, Rashid RM, Wu JJ. 308-nm excimer laser in psoriasis vulgaris, scalp psoriasis, and palmoplantar psoriasis. J Eur Acad Dermatol Venereol. 2009;23:36-41.
- Leonardi C, Sofen H, Krell J, et al. Phase IV study to evaluate the safety and efficacy of efalizumab for treatment of hand and foot plaque psoriasis. Presented at: 65th Annual Meeting of the American Academy of Dermatology. February 2007; Presentation 532.
- US Food and Drug Administration. FDA statement on the voluntary withdrawal of raptiva from the U.S. market. Available at: http://www.fda.gov/bbs/topics/NEWS/2009/NEW01992.html. April 2009. Accessed April 16, 2009.
- Genentech. Voluntary U.S. market withdrawal of raptiva (efalizumab). Available at: http://www.gene.com/gene/products/information/pdf/raptiva_withdrawal_dhcp.pdf. April 2009. Accessed April 16, 2009.
- Prossick TA, Belsito DV. Alefacept in the treatment of recalcitrant palmoplantar and erythrodermic psoriasis. Cutis. 2006;78:178-180.
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