Clinical and Therapeutic Pearls in Psoriasis

In this multispeaker session, psoriasis, its subtypes and its treatments, were reviewed. The clinical treatment of palmoplantar psoriasis, which should be considered separately from plaque psoriasis with palmar involvement, was covered by E. James Song, MD, who laid out his algorithm for management, starting with cyclosporine often combined with phototherapy, topicals, retinoids, and biologics before switching to methotrexate to maintain response. To mitigate adverse reactions with methotrexate, Dr. Song recommended increasing folic acid, splitting the daily dose, or adding ondansetron for GI intolerance, while nonspecific complaints may be helped by adding dextromethorphan on dosing days. He emphasized that treatment can’t be expected to mimic psoriasis vulgaris, and that monotherapy is often inadequate. JAK-inhibitors may be a promising new treatment for refractory disease as shown in a case series of 7 patients on tofacitinib.

Next a thought-provoking case series on patients with psoriasis developing spongiotic dermatitis following IL-17 inhibitor treatment was presented by Alice Gottlieb, MD. One patient discussed in particular failed subsequent anti-IL-23 treatment and, in the end, responded to upadacitinib, which also improved their psoriatic arthritis. Conversely, Dr. Gottlieb presented data on a small subset of patients with AD treated with dupilumab who developed enthesitis, arthritis and/or tenosynovitis suggestive of psoriatic arthritis (26 of 470). Symptoms ranged from mild, which could be treated with temporary discontinuation, dose reduction, or NSAIDs, to moderate-to-severe, which persisted for months despite reduction or discontinuation of dupilumab. 

Mark Lebwohl, MD gave us some actionable tips to prescribe oral PDE4 inhibitors for our patients and managing associated side effects. In a pooled analysis of patients with psoriasis (ESTEEM 1&2 trials) and psoriatic arthritis (PALACE 1 trial), treatment-associated diarrhea more commonly began within 1 week of starting apremilast and lasted for 1 to 2 weeks, compared to placebo-reported diarrhea. Taking apremilast with food and avoiding caffeine may be enough to ameliorate GI symptoms, but loperamide and fiber supplements are options for persistent or severe symptoms. His next tip focused on clinical administration of spesolimab for GPP, reminding us to assess for active infection, including WBC counts and/or CRP, if clinically indicated, prior to initiation in addition to tuberculosis testing. Dr. Lebwohl’s last pearl shed light onto psychiatric concerns with brodalumab for psoriasis patients with a history of depression. While vigilance is always recommended, detailed analysis of RCTs did not incur a causal relationship between completed suicides and brodalumab and in fact demonstrated improvements in Hospital Anxiety and Depression Scales with treatment.