CASE 5: Palmoplantar Psoriasis
A 63-year-old woman presents with
diffuse hyperkeratosis of the soles
and palms. She also has onycholysis-
separation of the nail plate from
the nail bed-and salmon-colored
plaques behind her ears. Biopsy of
one of the plaques confirms the suspected
diagnosis of psoriasis.
(Case and photographs courtesy of Joe Monroe, PA-C.)What would your treatment
plan include?
A REVIEW OF THE OPTIONSPalmoplantar psoriasis presents
with plaques and sterile pustules that
involve the palms and soles. This type
of psoriasis can significantly impair a
patient's ability to perform activities
of daily living.
Palmoplantar psoriasis often fails
to respond to topical therapy; topical
psoralen-UV-A (PUVA), however, is
highly effective. The patient soaks affected
areas in a dilute solution of
psoralen in water or applies a dilute psoralen cream for 30 minutes before
UV-A therapy. Topical PUVA is administered
2 or 3 times weekly; when
clearing is achieved, a maintenance
therapy program can be scheduled.
Sites that are treated with localized
topical PUVA require significant protection
from the sun; however, no
general eye and skin precautions are
necessary. If the patient does not respond
to PUVA therapy, systemic
retinoids may be added to the PUVA
regimen. Alternatively, systemic retinoids
may be prescribed alone or in
combination with a topical corticosteroid
and/orcalcipotriene. Methotrexate(and cyclosporine are other
treatment options.CASE 5:
APPROACH AND OUTCOMEA 4-month course of the oral
retinoid acitretin( ameliorated this patient's
disease.