What is the recommended treatment approach for palm psoriasis, including topical agents, phototherapy, and systemic therapies?

Treatment of Palmar Psoriasis

Start with combination therapy of a vitamin D analogue (applied in the evening) plus a high-potency topical corticosteroid (applied in the morning) as first-line treatment for palmar psoriasis. 1, 2

First-Line Topical Therapy

• High-potency topical corticosteroids under occlusion are the cornerstone of initial treatment, with the American Academy of Dermatology recommending this as the primary approach for palmar psoriasis 2

• Fixed combination products containing calcipotriol and corticosteroids are particularly effective and convenient for hand lesions, offering superior efficacy compared to monotherapy 1

• Apply vitamin D analogues in the evening and high-potency topical corticosteroids in the morning for optimal treatment response 1

Critical Precautions with Topical Therapy

• Never use salicylic acid simultaneously with calcipotriene as the acidic pH inactivates calcipotriene and reduces effectiveness 1

• Exercise caution with high-potency corticosteroids in finger web spaces and nail folds due to increased absorption and atrophy risk in these areas 1

• Absolutely avoid systemic corticosteroids as they can exacerbate psoriasis or provoke pustular forms upon discontinuation 1, 3

Second-Line Options for Inadequate Response (4-8 weeks)

• Add tazarotene 0.1% cream or gel for 8-12 weeks, particularly effective when combined with medium or high-potency topical corticosteroids 1

• Targeted phototherapy with 308-nm excimer laser is effective for localized palmar psoriasis 2

• Soak PUVA therapy (topical psoralen followed by UVA exposure) requires 2-3 times weekly treatments for several months and has demonstrated particular effectiveness for palmoplantar psoriasis 3, 2

• Topical calcineurin inhibitors are recommended for nail fold involvement as they don't cause skin atrophy 1

Systemic Therapy for Persistent or Severe Cases

Oral Retinoids (Preferred First-Line Systemic)

• Acitretin 25 mg daily is highly effective for palmar psoriasis, with substantial improvement typically within 2 months and response seen as early as 3 weeks in pustular variants 1, 3, 2

• Acitretin shows improvement in 84% of pustular psoriasis patients and is often considered first-line systemic therapy due to superior efficacy in this specific location 1, 2

• Critical contraindication: Acitretin requires a 3-year post-dosing pregnancy restriction in women of childbearing potential due to teratogenic effects 2

Alternative Systemic Agents

• Methotrexate is effective in 76.2% of pustular psoriasis cases and is FDA-approved for severe, recalcitrant, disabling psoriasis, though it requires monitoring for hepatotoxicity and bone marrow toxicity 1, 3, 2

• Cyclosporine is effective but should be used with caution due to nephrotoxicity risk 3, 2

• 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 2

Biologic Therapy for Refractory Cases

• Infliximab is recommended as a monotherapy treatment option for moderate-to-severe plaque psoriasis affecting the palms (plaque-type palmoplantar psoriasis) 4

• Infliximab at 5 mg/kg administered at weeks 0,2, and 6, then every 8 weeks has shown good clinical response (≥PPPASI 50) in palmoplantar psoriasis patients 4, 5

• Ustekinumab at 90mg dose has shown 67% clearance rate in patients with palmoplantar pustular psoriasis 1

• TNF inhibitors and IL-17 inhibitors should be considered for severe or treatment-resistant cases, especially with concurrent psoriatic arthritis 1, 3

Important Caveat with Biologics

• TNF-alpha antagonists can paradoxically induce pustular psoriasis of the palms and soles in patients without prior psoriasis history, so use with caution 3

Treatment Algorithm

1. Initiate combination therapy: Vitamin D analogue (evening) + high-potency topical corticosteroid (morning) under occlusion for 4-8 weeks 1, 2

2. If inadequate response, add tazarotene or switch to fixed combination product 1

3. For persistent cases after 8-12 weeks, initiate acitretin 25 mg daily (if no contraindications like pregnancy) 1, 3, 2

4. For severe or refractory cases, consider methotrexate or biologic therapy (infliximab, ustekinumab, or other TNF/IL-17 inhibitors) 4, 1, 3

Special Considerations

• Palmar psoriasis significantly impacts quality of life, justifying the use of systemic therapies when topical treatment is inadequate 3, 2

• Distinguish between plaque-type palmoplantar psoriasis and pustular psoriasis of palms/soles, as the latter is a distinct entity with different treatment considerations, though both respond to similar therapeutic approaches 4, 3

• For pustular psoriasis specifically, moderately potent topical corticosteroids (British National Formulary grade III) may relieve symptoms, with topical coal tar and dithranol providing additional benefit in some cases 4, 3