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(45.5%) patients in the control group treated with white petrolatum and salicylic acid.19

Thirty-nine patients with palmo- plantar psoriasis were treated with calcipotriol ointment, either twice weekly under occlusion overnight or twice daily with no occlusion, for six weeks. The results showed that at the end of treatment twice-weekly occlusive calcipotriol ointment was as effective as twice-daily application. No significant adverse effects were noted.17

Treatment of palmo-plantar psoriasis with biologics gives effective results, also in our experience, in those patients with severe lesions who are resistant to topical and conventional therapies. In an open label, 12-week study of adult patients treated with adalimumab 4mg every two weeks, 6 out of 11 patients showed overall improvement of at least one point on the Physician’s Global Assessment (PGA) scale at week 12 from baseline; four obtained a PGA of 0, and five patients had a 50% improvement compared with baseline. Improvement was more frequently achieved on the hands than on the feet.

Infliximab was shown to be effective in a study of 24 patients with palmo- plantar psoriasis unresponsive to at least four weeks treatment with potent or very potent topical corticosteroids or conventional systemic agents. Subjects were randomised to infliximab at 5mg/kg or placebo at weeks 0, 2 and 6. The infliximab group received further infusions at weeks 14 and 22. Patients receiving placebo were switched to infliximab at week 14, with additional infusions at weeks 16 and 20.20

At week

14, there was a mean 54% decrease in the surface area of the palms and soles affected by lesions in the infliximab- treated patients, compared with a 4.5% reduction in controls.20

By week 26, the

infliximab group had a 69% reduction in the lesional area, compared with baseline; controls crossed-over to infliximab at 14 weeks had a 43% decrease.21

At week 14, one-third of

patients in the infliximab arm had achieved a 75% reduction in their Palmoplantar Psoriasis Area and Severity Index score (PPASI), and two-thirds had reached PPASI50. In contrast, 8.5% of controls had a PPASI75.20


American Academy of Dermatology guidelines recommend first-line treatment of adults with palmo-plantar psoriasis with topical corticosteroids or

vitamin D derivatives or the combination betamethasone/calcipotriol with or without occlusion. Second-line treatments include acitretin as monotherapy or associated to phototherapy (either UVB or PUVA). Third-line therapies are conventional systemic therapies or biologics. Secukinumab 150 and 300mg was significantly more effective than placebo in patients with palmo-plantar psoriasis.20

In the GESTURE study

(n=205), a palmo-plantar Investigator Global Assessment (ppIGA) 0 or 1 response was achieved at week 16 (primary endpoint) by 22.1 and 33.3 versus 1.5% for placebo, respectively (p<0.001).20

8. Di Cesare A, Fargnoli MC, Peris K. Rapid response of scalp psoriasis to ustekinumab. Eur J Dermatol 2011;21(6):993–4.

9. Wozel G. News&file=article&sid=3561 (accessed 28 October 2015).

10. Scottish Intercollegiate Guidelines Network. Diagnosis and management of psoriasis and psoriatic arthritis in adults. guidelines/fulltext/121/index.html (accessed 24 September 2015).

11. National Institute for Health and Care Excellence. Clinical Knowledge Summaries. psoriasis#!scenario:6 (accessed 14 September 2015).

The change from baseline in

PPASI score was –35.3 and –54.6 versus –4.1 % of placebo, respectively (p<0.001).22

Conclusions Managing difficult to treat psoriasis is a therapeutic challenge for clinicians. However, the therapeutic scenario is improving, with the advent of new targeted therapies with promising efficacy profiles in hard to treat psoriasis and typically semi-non-responsive subgroups (for example, in prior biologic exposure etc). ●

References 1. National Institute for Health and Care Excellence. Psoriasis: The assessment and management of psoriasis. NICE clinical guideline 153. October 2012. (accessed 28 October 2015).

2. Reich K et al. Development of an adherence- enhancing intervention in topical treatment termed the topical treatment optimization program (TTOP). Arch Dermatol Res 2014;306(7):667–76.

3. Finlay AY. Current severe psoriasis and the rule of tens. Br J Dermatol 2005;152:861–7.

4. Sterry W et al. Biological therapies in the systemic management of psoriasis: International Consensus Conference. Br J Dermatol 2004;151(Suppl. 69):3–17.

5. Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008;58:826–50

6. Menter A et al. Section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol 2009;61(3):451–85.

7. Leonardi CL, Gordon KB. New and emerging therapies in psoriasis. Semin Cutan Med Surg 2014;33(2 Suppl 2):S37–41.

12. Crowley JJ et al. Treatment of nail psoriasis best practice recommendations from the Medical Board of the National Psoriasis Foundation. JAMA Dermatol. doi:10.1001/jamadermatol.2014.2983.

13. de Vries ACQ et al. Interventions for nail psoriasis. Cochrane Database Syst Rev 2013;Issue 1: CD007633.

14. European Medicines Agency. Cosentyx (secukinumab). jsp?curl=pages/medicines/human/ medicines/003729/human_med_001832. jsp&mid=WC0b01ac058001d124 (accessed 28 October 2015).

15. National Institute for Health and Care Excellence. Technology appraisal guidance 350. Secukinumab for treating moderate to severe plaque psoriasis. ta350 (accessed 28 October 2015).

16. Reich K et al. Secukinumab is effective in subjects with nail psoriasis: 16 week results from the TRANSFIGURE study [abstract]. In: 23rd World Congress of Dermatology;2015.

17. Frankel A, Goldenberg G. Insights into treating palmoplantar psoriasis. www.the-dermatologist. com/content/insights-treating-palmoplantar- psoriasis (accessed 28 October 2015).

18. Richetta AG et al. Safety an efficacy of adalimumab in the treatment of moderate to severe palmo-plantar psorisasis: an open label study. Clin Ter 2012;163(2):e61–6.

19. Kumar B, Kumar R, Kaur I. Coal tar therapy in palmoplantar psoriasis: old wine in an old bottle? Int J Dermatol 1997;36(4):309–12.

20. archive_pdf/vol40iss12/70622_main.pdf (accessed 28 October 2015).

21. Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: Case-based presentations and evidence-based conclusions. J Am Acad Dermatol 2011;65:137–74.

22. Gottlieb A et al. Secukinumab efficacy and safety in subjects with moderate to severe palmoplantar psoriasis in a phase 3b study (GESTURE). 23rd World Congress of Dermatology 2015: Abstr FC24-07.

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