Kicking off our first day of lectures in Miami, Dr Brad Glick reviewed his tips and tricks for treating challenging psoriasis, including when psoriasis ends up being something else entirely. In this case-based presentation, he reviewed therapies for unresponsive palmoplantar psoriasis, comorbidities that may impact treatment of plaque psoriasis and psoriatic arthritis, and a psoriasis look-a-like presenting as exfoliative dermatitis. 

In the first case, a 74-yo female with palmoplantar psoriatic disease who failed many biologic therapies including secukinumab, ustekinumab, and risankizumab was started on deucravacitinib with remarkable improvement in palms, soles, and scalp psoriasiform lesions. This novel TYK-2 inhibitor can be considered as an “add-on” therapy due to its complimentary mechanism of action to many other biologics and is a reminder that more challenging cases may require compound treatment regimens. 

In the second case, a former smoker with severe psoriasis, psoriatic arthritis, and a pertinent medical history of valvular heart disease, cerebral aneurysm, and obesity was walked through a variety of treatments with gradually improving responses. While more targeted therapies may have been partially contributing to this patient’s dramatic reduction in IGA, Dr Glick also proposed the importance of weight loss for obese patients with only moderate responses to treatment. Two articles that were cited examine the impact of bariatric surgery and weight loss in general on psoriatic disease. Another pearl in this case is to consider repeating positive QuantiFERON-TB Gold tests before removing patients from successful treatment regimens, as they may be false positives or laboratory errors. 
 

He ended with a case of severe exfoliative dermatitis unresponsive to many different therapies that, after review of an initial biopsy report by a second pathologist, was more consistent with pityriasis rubra pilaris. Islands of sparing were evident in clinical photos, and the patient responded to risankizumab and acitretin. In patients with exfoliative dermatitis, always test for scabies and take a detailed exposure history.