How I Treat: Psoriasis

An adult female patient presented to my dermatology practice with plaque psoriasis presenting on the hands and feet. Because of the localized nature of her disease and the involvement of such thick-skinned sites, I started her on topical clobetasol cream twice daily, and wet wraps with white cotton gloves were recommended after bedtime steroid application.

At follow-up 1 month later, the patient reported doing better, but she still had not achieved the agreed treatment goals. She was prescribed halobetasol propionate and tazarotene (HP/T) lotion, which was selected for its retinoid properties. For another two months of treatment, my patient experienced some improvement, but the choice was made to step up therapy to apremilast with HP/T lotion application in the morning and clobetasol cream application at night. We agreed upon the addition of apremilast given its relative safety, ease of use, and administration method (pill vs injection). With this combination approach, the patient cleared up to the point where she was happy with her results.

After 1 year, the patient presented again to the dermatology office with more widespread psoriasis. Instead of localized disease, she had bilateral plaques on the lower extremities as well as lesions on the trunk that were difficult to reach with topical therapy. She had a negative screening for psoriatic arthritis.

We had another discussion about the benefits and risks of adding or switching her therapy to a biologic agent. I explained that the newer biologics are extremely targeted and do not suppress the immune system as widely as older systemic options and additionally that these therapies, while injections, only have to be administered once every 1 to 3 months depending on what option we choose. The patient was receptive and agreed to systemic treatment with a biologic agent. She was started on a course of risankizumab, chosen for the infrequent number of injections.

Since initiation of biologic therapy, the patient has been clear and reported significant improvements.