Managing Plaque Psoriasis in Difficult-to-Treat Areas

Brad Glick, DO, MPH: Let’s talk about a challenging area to treat. Dr Stein Gold, you alluded to this before, about how patients are in the clinic and don’t want to say much about their psoriasis in certain locations. It’s a challenge to treat intertriginous areas. Linda, tell me how you manage plaque psoriasis when there’s involvement of the folds.

Linda Stein Gold, MD: You’re right. It can be a tremendous challenge. The first time I see a patient with psoriasis, I to ask them to undress. I try to do a full-skin check because that’s the only way you’re going to find out exactly what we’re dealing with. They might not want to tell you, but they want you to know that these are areas that have to be treated. Intertriginous areas can be a challenge. This includes the face because we can’t use potent topical steroids. We run the risk of having not only atrophy but also stria, and stria are not reversible. That’s where you’re going to have a challenge.

We can use lower-potency topical steroids, the topical immunomodulators, topical vitamin D, or topical tazarotene. But the drugs that we have, although they can be effective, especially in the sensitive areas or the skin folds, also have an irritation profile that can be very challenging. Overall, if you’re thinking about topical therapy, it’s a challenge. Some of our biologic agents and oral agents have been studied in these in intertriginous areas—face, scalp, and the genital area—and found to be quite effective. So that’s also an option.

Brad Glick, DO, MPH: Mona, what can you add to the conversation about intertriginous areas and your approach? We’re going to talk about this in a couple of moments. We have 2 new nonsteroidal therapies that are unique and can be used in these areas, but what has your approach been when you take care of patients who have involvement of their intertriginous folds?

Mona Shahriari, MD, FAAD: In addition to what Linda mentioned, for some of them, the speed of efficacy is important, especially when it comes to being intimate with a partner or overall comfort. In those individuals, I reach for an injectable agent or an oral agent so I can expedite the process. Let’s face it: putting a goofy cream in the groin area or under the breast isn’t the most pleasant experience. As you said, we go to some of our newer agents that have made that experience more pleasant. But historically, it’s been a challenge for our patients.

Transcript edited for clarity