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Patient Case #2: 60-Year-Old Female With Chronic Intertrigo


Dermatology experts discuss a patient case concerning a 60-year-old woman with chronic intertriginous psoriasis who is taking a biologic drug for inflammatory bowel disease.

James Q. Del Rosso, DO: We have a 60-year-old African American woman with moderate obesity with chronic intertrigo under her breast and under the abdominal folds. She has a 10-year history of psoriasis on the scalp and lateral face and notable disease relapses in this area. She does have a history of what is clinically evidence of psoriasis, and now she’s having intertriginous involvement. Although she experiences itchiness at the site, her main complaint, especially for those intertriginous areas, is that they are sometimes painful. They become sore and not just pruritic in those affected areas. She’s used a variety of different topical therapies and was told to use topical corticosteroids when symptoms flare. She did not find them to be effective and had the idea in her head that you have to be careful with them and how long you use them. So, she was using them somewhat gingerly; she wasn’t necessarily using them as consistently as you would want her to. She is currently on a biologic drug for inflammatory bowel disease, so considering other biologics is not an option. Any thoughts on that patient?

Nicholas Brownstone, MD: Other biologics are an option because we have multiple biologics that have indications for inflammatory bowel disease. So, you could switch her to another medication and see whether she could get better. But this is a great example of a case where we can go to a nonsteroidal option and use that safely for a long time, not worrying about the adverse effects that we would get when using a potent topical steroid in a skin fold or sensitive area. Therapies such as tapinarof are perfect for this case when we have intertriginous involvement affecting the patient greatly.

James Q. Del Rosso, DO: What’s interesting is the 2 new nonsteroidal agents that we have. Tapinarof and roflumilast were both evaluated and used in the trials in intertriginous areas. All the areas didn’t necessarily exclude elbows and knees. They didn’t exclude intertriginous areas. Roflumilast had a separate IgA for intertriginous disease, but it was still evaluated thoroughly in the tapinarof trials, and patients had excellent tolerability and good results in the intertriginous areas.

Nicholas Brownstone, MD: As Dawn said, if someone has 1% psoriasis…on the forearm vs 1% in the groin region, that’s a big difference. Patients want to get better, want to get better quickly, and they want to use something every day, get clear, and be able to maintain that.

James Q. Del Rosso, DO: The one-stop shopping is you’re not concerned about her using the tapinarof on the face.

Dawn L. Sammons, DO, FAOCD, FAAD: The dyspigmentation we can see with corticosteroids, especially in our…patients who have a higher Fitzpatrick score.

James Q. Del Rosso, DO: Well, she has a score of 5 or 6.

Dawn L. Sammons, DO, FAOCD, FAAD: Right. And we don’t know exactly from the description, but we know that she’s at risk of seeing some hypopigmentation over time with corticosteroids, especially in areas such as the face and around the scalp.

James Q. Del Rosso, DO: Brad, are you putting her on clobetasol?

Brad Glick, DO, FAOCD: I am not putting her on clobetasol. We’ve had other choices in the past that we would go to because of the corticosteroid use here. TCIs [topical calcineurin inhibitors] would be one of them, but we’ve learned that they’re irritating. We’ve had a previous PDE4 [phosphodiesterase-4] in crisaborole that maybe some of us tried in the intertriginous folds, and we’ve seen burning and stinging. We have a new agent, you just said yourself, which we can use.

James Q. Del Rosso, DO: Which is approved for atopic dermatitis, not necessarily psoriasis.

Brad Glick, DO, FAOCD: Exactly, we’d use that off label in this setting. And we’re reaching at straws, and we don’t have to reach out at straws right now because of a couple of agents, whether it’s tapinarof or roflumilast, for using in folds. I agree with Nick; although the verbiage here is that another biologic drug may not be another option in our space in dermatology, we have a biologic drug, risankizumab, approved for the skin, approved for the joints, and for the gut in inflammatory bowel disease, approved for Crohn disease. So, it is an option, but it doesn’t matter. The biologic therapies don’t clear our patients’ skin 100% of the time. So, we need these agents to add on. And right now, the add-on paradigm shift is also unique. Because what we would do and have been doing for the past 10 years or more in the biologic era is adding in corticosteroids. We weren’t adding in monotherapy vitamin D.

James Q. Del Rosso, DO: Maybe a combination. But the corticosteroid was still there.

Brad Glick, DO, FAOCD: A fixed combination, yes. But this changes the paradigm. I like those fixed combinations, but they are corticosteroids. They may be diluted, they may be a little milder, but they’re still higher-potency topical corticosteroids. That’s another unique part of the conversation. I see this as an add-on therapy example that’s fantastic, particularly because it’s occurring in her intertriginous folds. And I agree that the corticosteroids…are almost contraindicated here, because we know we’re going to have to use them for quite some time in the intertriginous fold. So having something that won’t cause that dyspigmentation and something that will reduce the inflammatory burden so that they won’t get postinflammatory hyperpigmentation, albeit they may have it already, is also very important.

James Q. Del Rosso, DO: The fact that there’s a lot of intertriginous involvement makes you want to stay away from topical corticosteroids. Even vitamin D analogues can be irritating in that case.

Transcript edited for clarity

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