What are the treatment options for palmar psoriasis?

Treatment Options for Palmar Psoriasis

For palmar psoriasis, a stepwise approach starting with topical therapies and progressing to systemic treatments is recommended, with oral retinoids being particularly effective for palmoplantar disease.

First-Line Topical Therapies

• High-potency topical corticosteroids are the initial treatment of choice for palmar psoriasis, particularly when used under occlusion to enhance penetration 1
• Combination therapy with vitamin D analogues (calcipotriene) and topical corticosteroids provides enhanced efficacy and is recommended as first-line treatment 2, 3
• Fixed combination products containing calcipotriol and corticosteroids are particularly effective and convenient for palmar lesions 2
• Topical tazarotene 0.1% cream can be used for palmar psoriasis, showing significant improvement when applied under occlusion 4, 2

Second-Line Topical and Phototherapy Options

• Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are recommended for areas prone to steroid-induced atrophy 5, 6
• Targeted phototherapy with 308-nm excimer laser is effective for localized palmar psoriasis 1
• Soak PUVA therapy, where patients soak their palms in methoxsalen solution for 15-30 minutes before UVA exposure, is particularly effective for palmoplantar psoriasis 1
• Topical PUVA requires treatments 2-3 times weekly for several months for adequate clearing and maintenance 1

Systemic Therapies for Moderate-to-Severe Disease

• Oral retinoids, particularly acitretin, are highly effective for palmar psoriasis and often considered first-line systemic therapy due to their efficacy in this specific location 1, 7
• Methotrexate is effective in a significant proportion of patients with palmoplantar psoriasis and is FDA-approved for severe, recalcitrant, disabling psoriasis 1, 8
• Cyclosporine is effective for palmoplantar psoriasis but should be used with caution due to potential nephrotoxicity 1
• Biologic agents, including TNF inhibitors (adalimumab), IL-17 inhibitors, and IL-23 inhibitors, should be considered for severe or treatment-resistant cases 1, 9

Treatment Algorithm for Palmar Psoriasis

1. Initial therapy: High-potency topical corticosteroids combined with vitamin D analogues for 4-8 weeks 2, 3
2. If inadequate response: Add tazarotene or switch to fixed combination product; consider occlusion to enhance penetration 4, 2
3. For persistent cases: Consider soak PUVA or targeted phototherapy 1
4. For moderate-to-severe or recalcitrant disease: Initiate systemic therapy with acitretin (if no contraindications like pregnancy) 1
5. If acitretin fails or is contraindicated: Consider methotrexate or cyclosporine 1
6. For severe or treatment-resistant cases: Consider biologic agents, particularly TNF inhibitors, IL-17 inhibitors, or IL-23 inhibitors 1, 9

Important Clinical Considerations

• Although palmar psoriasis affects a small percentage of body surface area, it is frequently debilitating, painful, and significantly impacts quality of life, justifying the use of systemic therapies 1
• Caution is needed when using acitretin in women of childbearing potential due to its teratogenic effects and 3-year post-dosing pregnancy restriction 1
• Methotrexate requires monitoring for hepatotoxicity and bone marrow toxicity, while cyclosporine requires monitoring for nephrotoxicity 1
• Combination therapy with acitretin and PUVA can enhance efficacy and reduce the number of PUVA treatments needed, potentially decreasing the risk of PUVA-associated skin malignancies 1
• Paradoxically, TNF-alpha antagonists have rarely been reported to induce palmoplantar pustular psoriasis in patients being treated for other conditions 1