Palmoplantar Psoriasis — SCE Dermatology MCQ

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ModerateInflammatory DermatosesPalmoplantar PsoriasisSCE Dermatology

A 55-year-old man has extensive plaque psoriasis with prominent involvement of his palms and soles. Palmoplantar psoriasis is often treatment-resistant. What is the recommended treatment approach for palmoplantar psoriasis not responding to potent topical corticosteroids?

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Correct answer: B — Escalate to hand/foot PUVA, Acitretin, or systemic therapy (including biologics) — palmoplantar psoriasis is a recognised indication for treatment escalation even with low PASI

The correct answer is B: escalate to hand/foot PUVA, acitretin, or systemic therapy (including biologics), because palmoplantar psoriasis is designated a high-impact, difficult-to-treat site by NICE regardless of the total body surface area affected. NICE CG153 specifically flags any involvement of nails, high-impact and difficult-to-treat sites such as palms and soles for specialist referral and escalation, since a low PASI does not capture the disproportionate functional disability (impaired grip, walking, occupational loss) these sites cause. Once potent topical corticosteroid (with or without occlusion or combination with vitamin D analogues) fails, options include localised hand/foot PUVA (the thick stratum corneum limits UVB penetration, favouring PUVA), oral acitretin (particularly effective in pustular palmoplantar disease), or non-biologic/biologic systemic therapy where impact on quality of life is significant, aligning with NICE's threshold-independent escalation pathway for high-impact sites.

Reference: https://www.nice.org.uk/guidance/conditions-and-diseases/skin-conditions