Exploring Advancements in Palmoplantar Pustulosis, Psoriasis Comorbidities, and Phototherapy

“There are a couple of hot topics going on right now in psoriasis. One is, can treating psoriasis with biologics lower the risk of psoriatic arthritis over time,” said Joel Gelfand, MD, in an interview with Dermatology Times at Fall Clinical 2024 in Las Vegas, Nevada.

Gelfand, professor of dermatology and epidemiology at the University of Pennsylvania Perelman School of Medicine in Philadelphia, Pennsylvania, recently presented “Palmoplantar Pustulosis: Looking Ahead to New Treatment Options” and “The Comorbidities of Psoriasis: What Clinicians Need to Know to Optimize Care.”

During his sessions, Gelfand discussed the complexities of treating palmoplantar pustulosis, the role of biologics in potentially lowering psoriatic arthritis risk, and the need for improved cardiovascular risk management in psoriasis patients through coordinated care models. He also highlighted findings from the LITE study, which demonstrated that home-based phototherapy is as effective as office-based phototherapy for psoriasis.

Gelfand’s Key Points

1. Palmoplantar Pustulosis Challenges and Treatment Insights

Palmoplantar pustulosis (PPP) is a complex dermatological condition primarily affecting the palms and soles, with treatment options that often lack consistent efficacy. During a recent session, Gelfand emphasized the challenging nature of treating PPP, noting that over 20 different therapies are frequently tried with limited success. PPP’s unique pathophysiology and genetic profile set it apart from other pustular diseases, such as generalized pustular psoriasis (GPP) and plaque psoriasis, further complicating treatment. Unlike GPP, which responds well to spesolimab, clinical trials indicate that spesolimab does not show efficacy for PPP, demonstrating the necessity of disease-specific treatments. Emerging research, such as a recent study in Japan, suggests that apremilast shows better responses than placebo in PPP, though the clinical significance for US patients remains uncertain. Despite these limitations, clinicians often trial apremilast as a monotherapy or in combination, reflecting the ongoing search for effective management strategies for PPP.

2. Psoriasis Comorbidities: Biologics, Psoriatic Arthritis, and Cardiovascular Risk

Gelfand highlighted recent findings on psoriasis comorbidities, particularly the impact of biologics on psoriatic arthritis (PsA) and cardiovascular risk management. Current research into whether biologics might reduce PsA risk is inconclusive, with studies showing varied results. Some evidence suggests that IL-23 inhibitors might be more effective in reducing PsA risk than TNF inhibitors, though conflicting findings in observational data indicate a need for large-scale clinical trials to establish clearer conclusions. Additionally, Gelfand pointed out the high prevalence of undiagnosed cardiovascular risk factors in psoriasis patients, including hypertension, hyperlipidemia, and diabetes. This gap highlights the importance of integrated care models. Through collaboration with the National Psoriasis Foundation, a centralized care coordination model has been developed, which involves dermatologists educating patients on cardiovascular risks, conducting initial screenings, and connecting patients with primary care providers for ongoing management. This model promotes comprehensive care while allowing dermatologists to remain efficient within their practice settings.

3. Home vs Office Phototherapy for Psoriasis

The LITE study, led by Gelfand and published in JAMA Dermatology, has provided substantial insights into the efficacy of phototherapy for psoriasis. As one of the largest academically led randomized controlled trials in the US, it enrolled 783 patients with psoriasis across 42 centers, examining the effectiveness of home-based vs office-based phototherapy. The study's diverse participant pool included a wide range of skin types, and findings demonstrated that home phototherapy achieved comparable results to office-based treatments. Notably, about 40% of participants had previously tried oral or biologic therapies, yet 12% continued on these medications, underscoring the demand for alternative treatment options. The study confirms that home phototherapy offers a viable, effective approach for managing psoriasis, presenting a paradigm shift that could broaden treatment accessibility and address unmet medical needs.

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