In this video, Dr George Han reviews challenging psoriasis conditions that may be seen in clinical practice.

Transcript: 

Hi, thanks for joining. My name is George Han. I'm an associate professor at the Icahn School of Medicine at Mount Sinai and the Zucker School of Medicine at Hofstra Northwell. 

It's my pleasure to talk to you today about a topic that's near and dear to my heart, which is complex psoriasis cases. We're going to talk about some situations where patients walk in, a little atypical, maybe unexpected, not your kind of run-of-the-mill psoriasis, and how to deal with them.  

The first one we'll talk about is eczematized psoriasis, and this is something where the patients often walk in and they'll do their own research, of course. “Dr Google,” right? They'll look at it, and they say, “I don't know if I have eczema or psoriasis,” but the truth is sometimes we don't know either. So, when you look at some of these cases, you know, they'll have features that mimic both psoriasis and eczema. So, you'll try to do all of your detective work, right? You're going to look at their fingernails. You're going to look at their scalp. You're going to try to figure out from the history what may be involved. 

But a lot of times, there are features that just are consistent and classic for both of these, right? They have well-demarcated plaques, but also excoriation, impetiginization, which you really don't see with psoriasis. And so, it's nice to know that this has been described. There's more and more work coming out and actually estimates that up to 5% to 10% of psoriasis patients can have some eczematized psoriasis features. 

So, I think it's an important topic to keep in mind because a lot of times, you do the biopsy, and the pathologist actually sees the same thing. They're going to see spongiosis for eczema and also psoriasiform hyperplasia, so it's not going to be clear even just doing a biopsy what's going on. 

What's helpful is that there's some idea of the pathophysiology now. It seems that certain IL-17 isoforms like IL-17C may be involved in the level of inflammation that we get with this condition. The other thing to keep in mind is these patients who come in, and they really have both of these conditions, and you really, sometimes you kind of bounce back and forth between a psoriasis biologic or an eczema biologic, and I have patients on both of them. 

But also, JAK inhibitors are a good fit in some cases for these patients because it does cover both the type 2 inflammation and the type 17, TH-17, inflammation for psoriasis. So, we do have treatment options that can help with this, so if you see that challenging patient, just be reassured it's not something that you're missing. It is something that's confusing for all of us.  

The next topic we'll talk about is palmoplantar psoriasis. This is something that's challenging because it really affects our patient's quality of life, and when the patients come in, again, we do our detective work, right? We try to figure out the area of the hand it's involving. We try to figure out the history. We look for the fissures. 

But a lot of times, it's challenging as well. I want to separate here the pustular palmoplantar psoriasis from the regular palmoplantar psoriasis because it seems all of these patients with the different forms of palmoplantar psoriasis are a little bit different. Our medications for psoriasis by and large don't work consistently well for pustular psoriasis on the hands and feet. 

So, I think that's an important thing to keep in mind. Our retinoids actually, those older class of medicines, can work well for those patients. When you look at palmoplantar disease by itself, if you have a patient who has psoriasis all over, it just happens to have hands and feet involved, I think you're pretty reassured going with your normal biologics there. 

The other thing to keep in mind is that when a patient has predominant hands and feet, meaning mostly psoriasis on the hands and feet, but very little elsewhere, our biologics are a little less consistent with that. When you look at the clinical trial outcomes for dedicated palmoplantar studies, it's oftentimes 20% to 30% lower, clear, almost clear, than the original trials where we do the subcut analysis, and this is important because the patients do behave a little differently. There is this school of thought out there that small molecules may be able to penetrate into those areas a little better, so that's something to keep in mind as well.  

Lastly, we're going to talk about erythrodermic psoriasis, when that patient walks in your door just covered with psoriasis. And there's a lot of ways this can happen, right? The patient just kind of put it off for so long, or something happened, right, a trigger. So, we know, for example, with generalized pustular psoriasis, which you have to make sure to differentiate that from regular psoriasis, a steroid taper preceding this may be a trigger. 

I think the important thing is to get them under control quickly because they can very quickly go into that erythrodermic form of psoriasis that gives them like sepsis-like symptoms, like, you know, fever, instability, and their blood pressure, you know, that's really not the path we want our patients to go down. In this case, we would probably optimize for a speed of response. So, as long as you can get the medication quickly, that's the key. 

If you have a sample laying around, a lot of us ask the question, “do I need to wait for that TB test to come back?” If you look at the data, the reactivation of TB is something that happens much further down the road, so like a year or 2 down the road when it does happen. So, I think there's no problem just starting them on the medication, waiting for the test to come back. Honestly, if it's positive, you just go ahead and treat it or set them up with ID to get treatment, but that shouldn't delay the treatment of the psoriasis that's all over.  

So, hopefully that's given you some tips for your patients that you're seeing. Thanks for tuning in it.