Pharmacotherapeutic approaches for treating psoriasis in difficult-to-treat areas

Abstract

Despite great therapeutic advancements in psoriasis, four notable difficult-to-treat areas including the scalp, nails, intertriginous (including genitals), and palmoplantar regions, pose a challenge to both physicians and patients. Localized disease of these specific body regions inflicts a significant burden on patients' quality of life and requires an adequate selection of treatments. Areas covered: This manuscript discusses appropriate therapies and important treatment considerations for these difficult-to-treat areas based on the available clinical data from the literature. Expert opinion: Clinical trials assessing therapies for the difficult-to-treat areas have been inadequate. With the first biological clinical trial for genital psoriasis pending publication, it is with hope that other biological agents will be evaluated for region-specific psoriasis. A greater understanding of the genetic and immunologic aspects of regional psoriasis, as well as identification of unique biomarkers, will further guide management decisions. For example, the recent discovery of the IL-36 receptor gene for generalized pustular psoriasis may prove valuable for other forms of psoriasis. Ultimately, identification of the most beneficial treatments for each psoriasis subtype and difficult-to-treat area will provide patients with maximal quality of life.

Treatment of Genital Psoriasis: A Systematic Review

“…Low-to-mid-potency topical corticosteroids are recommended as the first-line treatment for genital psoriasis [ 30 ] (grade of recommendation: D) and are commonly reported in the literature to be a critical component of treatment for these lesions. However, topical corticosteroids are generally approached with great caution for genital psoriasis patients because of the unique environment of the genitalia [ 31 ]. The thin skin and constant occlusion of this environment cause topical medications to have increased penetration in the groin area, which is a particular problem for infants, who have a high surface area-to-body mass ratio, predisposing them to systemic side effects.…”

A Case of Nail Psoriasis Successfully Treated with Intralesional Methotrexate

“…Nail psoriasis is a clinical diagnosis generally made in the context of existing psoriatic skin lesions [ 6 ]. Treatment of nail psoriasis is important given its association with decreased quality of life [ 7 ].…”

“…Treatment of nail psoriasis is challenging because of the anatomical properties of the nail unit that act as a barrier to active drug delivery and the naturally slow growth rate of the nail plate, which often delays noticeable clinical responses by months [ 6 ]. Although there have been many recent advances in the treatment of skin psoriasis, nail management is difficult, as no standardized therapeutic regimen currently exists [ 8 ].…”

“…Moreover, it averts known adverse effects of systemic therapies that have disappointing results but expose the patient to multiple risks such as hypertension and renal dysfunction with cyclosporine, neutropenia and elevated liver function tests with methotrexate, hyperlipidemia with acitretin, and infections and malignancies with biologic therapies [ 7 , 10 ]. Furthermore, this modality is a way of overcoming the problem of poor drug penetration encountered with topical treatment, essentially topical vitamin D 3 [ 6 ], and of availability, high cost, and the significant number of visits required with phototherapy and excimer light/laser treatment.…”

IL-36, IL-37, and IL-38 Cytokines in Skin and Joint Inflammation: A Comprehensive Review of Their Therapeutic Potential

“…In keeping with the critical role played by IL-36 in driving psoriatic-like skin inflammation and after the success of preclinical studies [60], IL-36R blocking antibodies have been developed for the treatment of psoriasis and are currently being tested in clinical trials [62,63].…”