CASE 5: Palmoplantar Psoriasis

A 63-year-old woman presents withdiffuse hyperkeratosis of the solesand palms. She also has onycholysis-separation of the nail plate fromthe nail bed-and salmon-coloredplaques behind her ears. Biopsy ofone of the plaques confirms the suspecteddiagnosis of psoriasis.(Case and photographs courtesy of Joe Monroe, PA-C.)What would your treatmentplan include?A REVIEW OF THE OPTIONSPalmoplantar psoriasis presentswith plaques and sterile pustules thatinvolve the palms and soles. This typeof psoriasis can significantly impair apatient's ability to perform activitiesof daily living.Palmoplantar psoriasis often failsto respond to topical therapy; topicalpsoralen-UV-A (PUVA), however, ishighly effective. The patient soaks affectedareas in a dilute solution ofpsoralen in water or applies a dilute psoralen cream for 30 minutes beforeUV-A therapy. Topical PUVA is administered2 or 3 times weekly; whenclearing is achieved, a maintenancetherapy program can be scheduled.Sites that are treated with localizedtopical PUVA require significant protectionfrom the sun; however, nogeneral eye and skin precautions arenecessary. If the patient does not respondto PUVA therapy, systemicretinoids may be added to the PUVAregimen. Alternatively, systemic retinoidsmay be prescribed alone or incombination with a topical corticosteroidand/orcalcipotriene. Methotrexateand cyclosporine are othertreatment options.CASE 5:APPROACH AND OUTCOMEA 4-month course of the oralretinoid acitretin ameliorated this patient'sdisease.