What is the recommended treatment for palmoplantar psoriasis?

Recommended Treatment for Psoriasis Involving the Hands

For moderate-to-severe palmoplantar psoriasis, begin with intensive topical therapy using clobetasol propionate 0.05% under occlusion for 8–12 weeks; if inadequate response, escalate to systemic acitretin 25 mg daily, which is the preferred first-line systemic agent for this location due to superior efficacy in palmar disease. 1, 2

Algorithmic Treatment Approach

Step 1: Intensive Topical Therapy (First-Line, 8–12 weeks)

• Apply clobetasol propionate 0.05% cream or ointment twice daily under occlusion (plastic wrap, gloves, or socks) to enhance penetration into the thick palmar skin 1, 2

• Combine with vitamin D analogues (such as calcipotriene) to augment efficacy; this combination is recommended by AAD/NPF guidelines 2

• Use urea 10% cream three times daily, including after hand washing, to provide keratolytic effects that help penetrate the hyperkeratotic plaques 1

• Common pitfall to avoid: Do not use systemic corticosteroids as monotherapy—they can precipitate life-threatening generalized pustular psoriasis 1

Step 2: Phototherapy (If No Response After 4 Weeks of Topicals)

• Soak PUVA is the phototherapy of choice for palmoplantar psoriasis, requiring 2–3 treatments weekly for several months; achieves clearance in 50–67% of cases 1, 2

• The risk of cutaneous malignancy on palms/soles after topical PUVA is very rare, unlike oral PUVA, making this a safer option 1

• Alternative phototherapy options include narrowband UVB or 308-nm excimer laser for localized lesions when PUVA is unsuitable 1, 2

Step 3: Systemic Therapy (Severe or Refractory Disease)

Acitretin (Preferred First-Line Systemic Agent)

• Start acitretin 25 mg orally daily—this is the most effective systemic agent specifically for palmoplantar psoriasis 1, 2, 3

• Expect substantial improvement within approximately 2 months (reduced scaling, thickness, and erythema) 1

• After disease control, taper to 25 mg on alternate days to maintain benefit 1

• Monitor lipid profile and liver enzymes every 1–2 months because acitretin raises triglycerides and cholesterol 1

• Critical safety consideration: Manage hypertriglyceridemia with fibrates and hypercholesterolemia with statins, but never combine both drug classes concurrently due to rhabdomyolysis risk 1

• Contraindication: Avoid in women of childbearing potential due to teratogenic effects and 3-year post-dosing pregnancy restriction 2

Alternative Systemic Agents

• Methotrexate 15–25 mg weekly is effective and FDA-approved for severe, recalcitrant psoriasis; requires baseline and periodic liver function tests and blood count monitoring 1, 2, 4

• Cyclosporine 2.5–5 mg/kg daily is effective but should be limited to ≤1 year due to nephrotoxicity; monitor renal function and blood pressure regularly 1, 2, 4

Step 4: Biologic Therapy (Refractory Cases)

• IL-17, IL-12/23 (ustekinumab), and IL-23 inhibitors are preferred over TNF-α blockers because head-to-head trials demonstrate higher skin-clearance rates 1

• Ustekinumab can be used as monotherapy for moderate-to-severe plaque psoriasis affecting the palms and soles (Grade B recommendation) 5

• Ustekinumab dosing: For patients ≤100 kg, use 45 mg subcutaneously initially and 4 weeks later, then every 12 weeks; for patients >100 kg, use 90 mg with the same schedule 5

• In the CLEAR trial, 67% of patients receiving the 90-mg dose achieved clearance compared with 9% receiving 45 mg (P = .02) 5

• Secukinumab and guselkumab are probably superior to placebo in reducing disease severity (moderate-quality evidence) 6

• Important caveat: TNF-α inhibitors (adalimumab, infliximab) can paradoxically induce pustular psoriasis of the palms/soles in approximately 1–2% of treated patients 1

When to Escalate Therapy

• Failure of intensive topical therapy after 8–12 weeks of occlusive superpotent corticosteroids warrants escalation to phototherapy or systemic agents 1

• Palmoplantar psoriasis justifies systemic therapy regardless of body-surface-area involvement because it causes disproportionate functional disability and quality-of-life impact 1, 2

Key Clinical Pitfalls

• Do not delay systemic therapy in severe palmar disease—the functional impairment justifies aggressive treatment even when total body surface area is small 1, 2

• Antihistamines are ineffective for psoriasis-related pruritus; they do not address the underlying inflammatory pathology 1

• Baseline laboratory monitoring is essential before initiating any systemic agent: complete blood count, liver function tests, and lipid panel 1