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Challenging Cases, Featuring Tips From the Psoriasis Experts

In a psoriasis-focused, 2-hour digital workshop at Maui Derm Connect, Dr Bruce Strober held a roundtable with Drs Linda Stein Gold, Arthur Kavanaugh, and Joel Gelfand to highlight treatment strategies in various challenging cases of the papulosquamous disease.

Dr Strober is clinical professor of dermatology at Yale University School of Medicine in New Haven, CT, and co-founder of Central CT Dermatology in Cromwell. Dr Stein Gold is director of dermatology clinical research at Henry Ford Health System in Detroit, MI, and division head of dermatology at Henry Ford Health System in West Bloomfield, MI. Dr Kavanaugh is professor of medicine at the University of California, San Diego (UCSD) School of Medicine, as well as the director of the Center for Innovative Therapy in the UCSD division of rheumatology, allergy, and immunology. Dr Gelfand is professor of dermatology and of epidemiology, vice chair of clinical research and medical director of dermatology clinical studies unit, director of Psoriasis and Phototherapy Treatment Center, University of Pennsylvania Perelman School of Medicine in Philadelphia.

The first case highlighted by the group was a patient with scalp psoriasis. Dr Gelfand started the discussion off by highlighting a Swedish study that pointed to a correlation between scalp psoriasis and a more aggressive disease. Dr Stein Gold noted she finds success with an intralesional Kenalog injection when the psoriasis presents on the occipital scalp, particularly in patients who are responding to biologics well elsewhere on the body. The group also noted a need to move away from IL-17 therapies in patients who present with sebopsoriasis of the scalp, given the increased risk of fungal infection for this therapeutic class.

Dr Strober then moved to nail psoriasis, stressing that dermatologists need to explain to patients that results may be a little bit prolonged given than the nails grow at a slow rate. Dr Kavanaugh, bringing in his rheumatology expertise, explained that there may be a sort of ascertainment bias when it comes to linking nail psoriasis with psoriatic arthritis (PsA) involvement. In these cases, Dr Kavanaugh noted, dermatologists are looking at the hand and joints up close because of nail presentation, so this case may trigger questions about PsA signs and symptoms.

Drs Gelfand and Stein Gold offered some advice on treatment approaches. Dr Stein Gold said she does not believe in a topical approach to nail psoriasis, instead opting for more Kenalog injections. She advised that needles should be changed very frequently and that injections to the matrix are preferred. Dr Gelfand also suggested Kenalog injections, saying some colleagues do well with using a buzzing device to assist with injection pain, but he also said he will use systemic agents almost immediately in these cases.

The group then described how to handle conversations with patients who are concerned about the risk of malignancy with the various psoriasis therapies, particularly TNF inhibitors. Because the severity of their disease and the need for effective treatment, Dr Stein Gold said that dermatologists should remember that our patients with psoriasis are going to read the label of their therapies, so providers should be prepared to have this discussion with them. Dr Kavanaugh further explained that the TNF inhibitor data for solid tumor malignancy is good with an overall low risk, but the “sticky area” is lymphoma. Dermatologists should explain that while the risk is low, there is never a full guarantee against malignancy.

Reference
Strober B, Stein Gold L, Kavanaugh A, Gelfand J. Challenging cases in psoriasis. Presented at: Maui Derm Connect; January 25-29, 2021; Maui, HI.

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