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Patient Case #1: 29-Year-Old Female With Plaque Psoriasis


Dawn L. Sammons, DO, FAOCD, FAAD, and Benjamin Lockshin, MD, FAAD, review a case of a female patient with a family history of plaque psoriasis.

James Q. Del Rosso, DO: We have a 29-year-old woman who comes to the clinic complaining of red, scaly plaques on various parts of the body. They’ve been present for a few months. She only has a few areas, but she’s noticing that they’re getting worse. She’s seeing 1 or 2 more every so often. She’s tried over-the-counter moisturizers and creams, but not much is helping. She has strong family history of psoriasis, so she’s concerned about that. She wants to understand her treatment options and what might be done to prevent her psoriasis from getting worse because she understands there’s a long delay in response time. She doesn’t necessarily want to go on systemic treatment, and life therapy is not convenient for her in her personal life and travel schedule. Any thoughts on that case?

Dawn L. Sammons, DO, FAOCD, FAAD: First, you have a young female patient who’s probably self-conscious, so she doesn’t want to start something systemic. So, I think we’re looking for something topical. Five years ago, she would have walked out of my office with a topical corticosteroid. We’d start there, send her home, bring her back in a couple of months, and see what she looked like in 6 weeks. Today that looks a lot different. I don’t write as many prescriptions for corticosteroids for initial presentation of psoriasis anymore. We have too many options for topicals, so in this situation I would have started with one of the newer topicals with a new mechanism of action where I can send her home. What we don’t know is whether it pops up elsewhere, and that’s always my fear. These patients are going to go home, and when they present to me and I give them a topical steroid, it’s only on their elbows, knees, and maybe their shins. They come back 6 or 8 weeks later, and now it’s on their ears and their eyelids.

James Q. Del Rosso, DO: And they’re putting on the corticosteroids.

Dawn L. Sammons, DO, FAOCD, FAAD: And they would say, “Oh my goodness.” They’re putting it under the breast and other places. So I love the fact that now we have options that work in many ways better than the steroids I was using. I’ve seen better and faster results, and yet I don’t have to have those concerns. I can give them 1 tube to use everywhere.

James Q. Del Rosso, DO: Ifshe develops a new area of psoriasis, you’re not concerned that she’s starting to manage that as you would be with the steroid.

Dawn L. Sammons, DO, FAOCD, FAAD: Right. Most of us have been around long enough to remember that we sent patients out with 2 or 3 tubes. You had to have 1 tube for the face and the body folds and another tube for the knees and elbows.

James Q. Del Rosso, DO: And a solution for the scalp.

Dawn L. Sammons, DO, FAOCD, FAAD: How many patients got that right? Not a lot.

Benjamin Lockshin, MD, FAAD: I would say that we all struggle with that game of whack-a-mole as Dawn was saying. And that condition sometimes goes into areas that we don’t see in our clinic, so if we see it traditionally on the trunk or the extremities and it migrates to intertriginous areas of the face, they might think they’ve got free range to use whatever they want.

James Q. Del Rosso, DO: Or they don’t think it’s psoriasis. If it’s in the groin, they think it’s a yeast infection or something else and they don’t even tell you about it because it doesn’t look the same. It’s red, but it doesn’t get as scaly because of the moisture. Unless you look, they don’t bring it to your attention if it’s in the axilla or the groin.

Benjamin Lockshin, MD, FAAD:I make a point to always ask patients whether they have involvement in the genital area. If you don’t ask, they won’t tell, because they’re either embarrassed or don’t know it’s related to what else is going on.

James Q. Del Rosso, DO: You can’t say, “Do you have psoriasis in those areas?” But instead you can say, “Do you have redness in there?” Because they don’t think it’s psoriasis; they think it’s something else.

Brad Glick, DO, FAOCD: I would manage it the same way. A year ago, I would have given you a different answer. I hate to add this buzz phrase “paradigm shift,” but it may be true. And as I’m listening, I’m buying into it myself.

James Q. Del Rosso, DO: You’re softening up as this corticosteroid guy. We’re getting to you. Brad Glick is shifting over.

Benjamin Lockshin, MD, FAAD: It’s funny because Brad is almost on the opposite end of the spectrum. In a situation such as this, prior to the introduction of these newer generation topicals, I would have been thinking, “Oh, let’s have this conversation about the systemic therapy,” because we are going to play whack-a-mole. I’m going to be concerned about the long-term effects. She’s 29, she’s got her whole life ahead of her, and Nick had mentioned the concerns about atrophy over long term. This is a marathon, not a sprint, so having newer medications such as tapinarof that allow us to use this where you feel it’s appropriate, when you feel it’s appropriate, with the possibility of having the remittive effect and long-term clearance, means a lot to me and has delayed the introduction to systemic therapies for many patients such as her.

Transcript edited for clarity

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