Psoriatic lesions affecting the scalp, nails, palms, and the soles of the feet are described as difficult-to-treat psoriasis and require specific management. Involvement of these sites often has a significant physical and emotional impact on the patient and the lesions are difficult to control with topical treatments owing to inadequate penetration of active ingredients and the poor cosmetic characteristics of the vehicles used. Consequently, when difficult-to-treat sites are involved, psoriasis can be considered severe even though the lesions are not extensive. Scant information is available about the use of biologic therapy in this setting, and published data generally comes from clinical trials of patients who also had moderate to severe extensive lesions or from small case series and isolated case reports. In this article we review the quality of the scientific evidence for the 4 biologic agents currently available in Spain (infliximab, etanercept, adalimumab, and ustekinumab) and report level i evidence for the use of biologics to treat nail psoriasis (level of recommendation A) and a somewhat lower level of evidence in the case of scalp involvement and palmoplantar psoriasis.

Fig. 1. Clinical images. a) Patient #13. Symmetrically distributed hyperpigmented macules with a reticular disposition affecting the perineal area. Note the 2 nodules and the non-draining fistula. b) Patient #13. Comedon-like infundibular cysts and follicular plugging. c) Patient #14. Typical DDD hyperpigmented macules in major skinfolds. Note the inflamed abscess in the perineal area. d) Patient #14. Note the non-inflammatory nodules in the right axillae, hyperpigmentation and multiple doublecomedon openings.

No abstract

No abstract