From the Guidelines
Pityriasis rubra pilaris (PRP) should be treated with PUVA as the first-line phototherapy, according to the most recent and highest quality evidence available 1.
Treatment Overview
Treatment for PRP typically begins with topical therapies for mild cases and progresses to systemic medications for more severe or widespread disease.
- First-line topical treatments include high-potency corticosteroids and emollients to manage scaling and dryness.
- For moderate to severe PRP, oral retinoids are the mainstay of therapy, with acitretin being the preferred option, though isotretinoin may also be effective.
- Methotrexate represents another systemic option, particularly when retinoids are contraindicated.
- For refractory cases, biologics such as TNF-alpha inhibitors or IL-12/23 inhibitors have shown promise.
Phototherapy
- Phototherapy, particularly PUVA, can be used as adjunctive treatment, as it remains an important treatment for PRP, being the first-line phototherapy for this condition 1.
- Narrowband UVB may be contraindicated in adult PRP and should be used with caution, as suggested by other reports 1.
- Most patients require 3-6 months of therapy before significant improvement occurs, and treatment should continue until remission.
Supportive Care
- During treatment, patients should be monitored for medication side effects and should use sun protection as many treatments increase photosensitivity.
- Supportive care with regular moisturizing and gentle skin care is essential throughout the treatment course.
- The British Association of Dermatologists and British Photodermatology Group guidelines support the use of PUVA for PRP, highlighting its effectiveness and importance in treatment 1.
From the FDA Drug Label
For Dermatologic Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin in hyperkeratotic skin disorders including ... pityriasis rubra pilaris,
- Salicylic Acid 6% is a topical aid in the treatment of pityriasis rubra pilaris.
- It is used for the removal of excessive keratin in hyperkeratotic skin disorders. 2
From the Research
Treatment Options for Pityriasis Rubra Pilaris
- Topical and systemic agents, as well as physical modalities, have been used to treat pityriasis rubra pilaris (PRP) 3
- A systematic review suggests a continuous topical treatment and, when appropriate, in combination with phototherapy, with retinoids as first-line therapy, and a combination of retinoid and methotrexate, azathioprine, or cyclosporine A as second-line therapy 3
- Biologicals can be used as third-line therapy, and in case of treatment failure, can be combined with a retinoid, methotrexate, or cyclosporine A 3
Systemic Therapies for PRP
- A systematic review of systemic treatments for PRP found that retinoids achieved an excellent response in 42.0% of patients, with isotretinoin being the most effective (61.1%) 4
- Methotrexate achieved an excellent response in 33.1% of patients, while biologicals were successful in 51.0% of patients, with ustekinumab being the most effective (62.5%) 4
- The review suggests a treatment regimen starting with isotretinoin as first-line, methotrexate as second-line, and biologicals as third-line treatment for PRP 4
Case Reports and Series
- A case report describes the successful treatment of PRP with a combination of infliximab and methotrexate 5
- Another case report describes the successful treatment of PRP with adalimumab 6
- A retrospective study of 28 patients with PRP found that acitretin was the most common therapy, and that methotrexate, cyclosporine, and biologics such as ustekinumab and infliximab were effective treatments 7