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Managing Hand and Foot Psoriasis

Managing Hand and Foot Psoriasis

Systemic Retinoids

Of the systemic retinoids, acitretin is the primary drug of choice.6 Because of its teratogenicity, its use is generally restricted to men and women who cannot become pregnant. Women of childbearing age should not be given acitretin. Acitretin has a number of mucocutaneous side effects, such as hair loss and dryness. These side effects can often be addressed by using low doses of the drug. While such doses may not clear psoriasis plaques, they may still provide sufficient improvement in the disease to improve patients’ function and quality of life. 

Cyclosporine

Cyclosporine is a highly effective treatment that can rapidly clears palmoplantar psoriasis in most patients, but its use is limited by long-term toxicities, particularly renal damage.7 Cyclosporine may be best for short term use to achieve rapid clearing before transitioning patients to a safer long term treatment.

TNF Inhibitors

Tumor necrosis factor-α (TNF) inhibitors are effective for palmoplantar psoriasis. Adalimumab (Humira) was tested in a randomized placebo-controlled study that included 72 patients.  A Physician Global Assessment of hands and/or feet score of clear or almost clear was achieved in adalimumab patients about a third of the time.8 Infliximab and etanercept (Enbrel) also can be effective choices.9

Interleukin 23 Inhibitors

Ustekinumab (Stelara) is another option that has been demonstrated to be effective in patients with palmoplantar psoriasis (plaque and pustular types) in case reports and case series.10,11 

Newer IL-23 inhibitors—guselkumab (Tremfya), tildrakizumab-asmn (Ilumya), and risankizumab-rzaa (Skyrizi)—are FDA approved; another, mirikizumab, is still in development. These agents are also promising treatments for palmoplantar psoriasis.

Interleukin 17A Inhibitors

In post hoc subgroup analyses of patients with palmoplantar psoriasis treated with ixekizumab (Taltz) 80 mg every 2 weeks for 12 weeks, 52% achieved a 100% improvement compared to only 8% of placebo patients.12 In the GESTURE study, which evaluated secukinumab (Cosentyx) in more than 200 patients with palmoplantar psoriasis,13 one-third of the patients were clear or almost clear of the palmoplantar psoriasis at week 16.   

In another study of patients with the pustular type of palmoplantar psoriasis who were treated with secukinumab, about one in four patients had a 75% improvement in their disease.14 Pustular psoriasis on the hands and feet may respond more poorly than typical psoriasis plaques in these areas.

Apremilast

In a study that evaluated apremilast (Otezla) in patients with palmoplantar psoriasis, only about 14% of patients were clear or almost clear. Still, apremilast may be a reasonable options as  quality of life and work productivity were improved.15 This highlights that patients may achieve important improvements, even if they do not achieve full or almost full clearance.

Future Therapies

On the frontier of palmoplantar psoriasis management are several new treatments: the IL-23 inhibitors, for which more data are needed; the topical and systemic Janus kinase inhibitors, none of which are approved yet for psoriasis; and perhaps an IL-36 receptor antagonist, which appears effective for generalized pustular psoriasis. Palmoplantar psoriasis is debilitating for patients and challenging to treat. Fortunately, with currently available options, good outcomes may be achieved. 

 

Mr Sonnenreich is freelance writer based in Washington, D.C. 

Mr Wolley is a freelance writer based in Washington, D.C. 

Ms Geisler, MA, is a freelance medical editor and writer based in Westbury, CT.

 

Disclosures: The authors report no relevant financial relationships.

References

1. Kumar B, Saraswat A, Kaur I. Palmoplantar lesions in psoriasis: a study of 3065 patients. Acta Derm Venereol. 2002;82(3):192-195. doi:10.1080/00015550260132488

2. Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005;64(suppl. 2):ii18-ii123. doi:10.1136/ard.2004.033217

3. Pettey AA, Balkrishnan R, Rapp SR, Fleischer AB, Feldman SR. Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice. J Am Acad Dermatol. 2003;49(2):271-275.

4. Farley E, Masrour S, McKey J, Menter A. Palmoplantar psoriasis: a phenotypical and clinical review with introduction of a new quality-of-life assessment tool. J Am Acad Dermatol. 2009;60(6):1024-1031. doi:10.1016/j.jaad.2008.11.910

5. Janagond AB, Kanwar AJ, Handa S. Efficacy and safety of systemic methotrexate vs. acitretin in psoriasis patients with significant palmoplantar involvement: a prospective, randomized study. J Eur Acad Dermatol Venerol. 2013;27(3):e384-e389. doi:10.1111/jdv.12004

6. Marsland AM, Chalmers RJ, Hollis S, Leonardi-Bee J, Griffiths CE. Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev. 2006;(1):CD001433. doi:10.1002/14651858.CD001433.pub2

7. Reitamo S, Erkko P, Remitz A, Lauerma AI, Montonen O, Harjula K. Cyclosporine in the treatment of palmoplantar pustulosis. A randomized, double-blind, placebo-controlled study. Arch Dermatol. 1993;129(10):1273-1279. doi:10.1001/archderm.1993.01680310043006

8. Leonardi C, Langley RG, Papp K, et al. Adalimumab for treatment of moderate to severe chronic plaque psoriasis of the hands and feet: efficacy and safety results from REACH, a randomized, placebo-controlled, double-blind trial. Arch Dermatol. 2011;147(4):429-436. doi:10.1001/archdermatol.2010.384.

9. Leonardi C, Langley RG, Papp K, et al. Adalimumab for treatment of moderate to severe chronic plaque psoriasis of the hands and feet: efficacy and safety results from REACH, a randomized, placebo-controlled, double-blind trial. Arch Dermatol. 2011;147(4):429-436.

10. Bulai Livideanu C, Lahfa M, Mazereeuw-Hautier J, Paul C. Efficacy of ustekinumab in palmoplantar psoriasis. Dermatology. 2010;221(4):321-323. doi:10.1159/000320961

11. Buder V, Herberger K, Jacobi A, Augustin M, Radtke MA. Ustekinumab in the treatment of palmoplantar pustular psoriasis -- a case series of nine patients. J Dtsch Dermatol Ges. 2016;14(11):1108-1113. doi:10.1111/ddg.12825

12. Menter A, Warren RB, Langley RG, et al. Efficacy of ixekizumab compared to etanercept and placebo in patients with moderate-to-severe plaque psoriasis and non-pustular palmoplantar involvement: results from three phase 3 trials (UNCOVER-1, UNCOVER-2 and UNCOVER-3). J Eur Acad Dermatol Venereol. 2017 Oct;31(10):1686-1692.

13. Gottlieb A, Sullivan J, van Doorn M, et al. Secukinumab shows significant efficacy in palmoplantar psoriasis: results from GESTURE, a randomized controlled trial. J Am Acad Dermatol. 2017;76(1):70-80. doi:10.1016/j.jaad.2016.07.058

14. Mrowietz U, Bachelez H, Burden AD, et al. Secukinumab for moderate-to-severe palmoplantar pustular psoriasis: results of the 2PRECISE study. J Am Acad Dermatol. 2019;80(5):1344-1352. doi:10.1016/j.jaad.2019.01.066 

15. Bissonnette R, Haydey R, Rosoph LA, et al. Apremilast for the treatment of moderate-to-severe palmoplantar psoriasis: results from a double-blind, placebo-controlled, randomized study. J Eur Acad Dermatol Venereol. 2018;32(3):403-410. doi:10.1111/jdv.14647

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