Treatment of Inverse/Intertriginous Psoriasis: Updated Guidelines from the Medical Board of the National Psoriasis Foundation

August 2017 | Volume 16 | Issue 8 | Original Article | 760 | Copyright © August 2017


Hasan Khosravi MD,a Michael P. Siegel PhD,b Abby S. Van Voorhees MD,c and Joseph F. Merola MD MMSca,d

aHarvard Medical School, Boston, MA bNational Psoriasis Foundation, Portland, OR cEastern Virginia Medical School, Norfolk, VA dBrigham and Women’s Hospital, Boston, MA

Lastly, systemic agents such as methotrexate, anti-TNF, anti-IL12/ IL23 inhibitors, oral PDE4 inhibitors, and anti-IL17 can be considered. While these therapies have been evaluated for plaque psoriasis, their use in inverse psoriasis has not been well-studied. Our literature review revealed two case reports demonstrating efficacious treatment with adalimumab and ustekinumab.34,35 Further randomized control studies need to evaluate the efficacy and safety of biologics for inverse psoriasis. However, based on clinical experience, these agents have shown significant efficacy and should be strongly considered in patients suffering from severe, topical-resistant inverse psoriasis. As mentioned previously, this review is limited by the lack of clinical trials in inverse psoriasis. For example, the number of patients in these studies is small and there are few meta-analyses or randomized, controlled trials. The authors of this report hope that future studies will add to the limited body of knowledge. In these future clinical studies, it is important to use a psoriasis severity index inclusive of inverse and genital psoriasis along with patient-reported outcomes. The Comprehensive Assessment of the Psoriasis Patient is one such index that takes into account non-plaque phenotypes and incorporates patient- derived, patient-reported outcomes.44 The use of this index could possibly allow for more robust drug development.

CONCLUSION

The primary treatment for inverse psoriasis continues to be low-potency topical steroids for short periods (less than 2-4 weeks).10 However, in order to avoid steroid side-effects with long-term treatment, topical therapies such as tacrolimus, pimecrolimus, calcitriol, or calcipotriene should be considered. Second and third-line therapies such as antimicrobial therapy, emollients, and tar-based products have been used anecdotally. Severe involvement that is resistant to topical therapy can be treated with botox injections, excimer laser therapy, or systemic agents; despite anecdotal evidence demonstrating the strong clinical efficacy of biologic treatment, we currently have limited knowledge on the effects of biologics on intertriginous or genital psoriasis. With randomized controlled trials and incorporation of objective severity indices inclusive of non-plaque phenotypes, we hope further treatment assessment can be performed.

DISCLOSURES

Dr Siegel is employed by the National Psoriasis Foundation. The Foundation receives unrestricted nancial support from AbbVie, Inc, Amgen, Inc, Celgene Corporation, Eli Lilly and Co, Janssen Biotech, Inc, LEO Pharma Inc, Novartis Pharmaceuticals, and Pfizer, Inc. Dr. Van Voorhees has served as a consultant and/or investigator for the following companies including: AbbVie, Amgen, Aqua, Astra Zeneca, Celgene, Corrona, Dermira, Jannsen, Leo, Lilly, Merck, Pfizer, and Valeant. Dr. Merola has served as a consultant, speaker, board of director member, advisory board member, and/or investigator for the following companies including: AbbVie, Amgen, Biogen IDEC, Boehringer Ingelheim, Jannsen, Leo, Eli Lilly, Merck, Mollinckrodt, Novartis, Pfizer, and UCB. Hasan Khosravi has no conflict of interests to declare. This work was funded by the National Psoriasis Foundation, Portland, OR.

REFERENCES

  1. Omland SH, Gniadecki R. Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris? Clin Dermatol. 2015;33(4):456-461. 
  2. Merola JF, Li T, Li WQ, et al. Prevalence of psoriasis phenotypes among men and women in the USA. Clin Exp Dermatol. 2016;41(5):486-489. 
  3. Lin J MJ, Li T, Han J, Qureshi AA. The association between inverse psoriasis and risk of psoriatic arthritis. 
  4. Morris A, Rogers M, Fischer G, Williams K. Childhood psoriasis: a clinical review of 1262 cases. Pediatr Dermatol. 2001;18(3):188-198. 
  5. Meeuwis KA, de Hullu JA, de Jager ME, et al. Genital psoriasis: a questionnaire-based survey on a concealed skin disease in the Netherlands. J Eur Acad Dermatol Venereol. 2010;24(12):1425-1430. 
  6. Ryan C, Sadlier M, De Vol E, et al. Genital psoriasis is associated with significant impairment in quality of life and sexual functioning. J Am Acad Dermatol. 2015;72(6):978-983. 
  7. Meeuwis KA, van de Kerkhof PC, Massuger LF, et al. Patients’ experience of psoriasis in the genital area. Dermatology. 2012;224(3):271-276. 
  8. Cohen J KH, Joyce C, Patel M, et al. J Drugs Dermatol. 2016;15(8):1011-1016. . 
  9. Berth-Jones J. Prescribing in psoriasis. Practitioner. 1994;238(1536):231-234. 
  10. Kalb RE, Bagel J, Korman NJ, et al. Treatment of intertriginous psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol. 2009;60(1):120-124. 
  11. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318(7183):593-596. 
  12. Kreuter A, Sommer A, Hyun J, et al. 1% pimecrolimus, 0.005% calcipotriol, and 0.1% betamethasone in the treatment of intertriginous psoriasis: a double-blind, randomized controlled study. Arch Dermatol. 2006;142(9):1138-1143. 
  13. Lebwohl MG, Tan MH, Meador SL, Singer G. Limited application of uticasone propionate ointment, 0.005% in patients with psoriasis of the face and intertriginous areas. J Am Acad Dermatol. 2001;44(1):77-82. 
  14. Ortonne JP, Humbert P, Nicolas JF, et al. Intra-individual comparison of the cutaneous safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or exural areas. Br J Dermatol. 2003;148(2):326-333. 
  15. Lebwohl M, Freeman AK, Chapman MS, et al. Tacrolimus ointment is effective for facial and intertriginous psoriasis. J Am Acad Dermatol. 2004;51(5):723-730. 
  16. Gribetz C, Ling M, Lebwohl M, et al. Pimecrolimus cream 1% in the treatment of intertriginous psoriasis: a double-blind, randomized study. J Am Acad Dermatol. 2004;51(5):731-738. 
  17. Liao YH, Chiu HC, Tseng YS, Tsai TF. Comparison of cutaneous tolerance and efficacy of calcitriol 3 microg g(-1) ointment and tacrolimus 0.3 mg g(-1) ointment in chronic plaque psoriasis involving facial or genitofemoral areas: a double-blind, randomized controlled trial. Br J Dermatol. 2007;157(5):1005-1012. 
  18. Freeman AK, Linowski GJ, Brady C, et al. Tacrolimus ointment for the treatment of psoriasis on the face and intertriginous areas. J Am Acad Dermatol. 2003;48(4):564-568. 
  19. Martin Ezquerra G, Sanchez Regana M, Herrera Acosta E, Umbert Millet P. Topical tacrolimus for the treatment of psoriasis on the face, genitalia, intertriginous areas and corporal plaques. J Drugs Dermatol. 2006;5(4):334-336. 
  20. Brune A, Miller DW, Lin P, et al. Tacrolimus ointment is effective for psoriasis on the face and intertriginous areas in pediatric patients. Pediatr Dermatol. 2007;24(1):76-80. 
  21. Rallis E, Nasiopoulou A, Kouskoukis C, et al. Successful treatment of genital and facial psoriasis with tacrolimus ointment 0.1%. Drugs Exp Clin Res. 2005;31(4):141-145. 
  22. Bissonnette R, Nigen S, Bolduc C. Efficacy and tolerability of topical tacrolimus ointment for the treatment of male genital psoriasis. J Cutan Med Surg. 2008;12(5):230-234. 
  23. Steele JA, Choi C, Kwong PC. Topical tacrolimus in the treatment of inverse psoriasis in children. J Am Acad Dermatol. 2005;53(4):713-716.
  24. Kienbaum S, Lehmann P, Ruzicka T. Topical calcipotriol in the treatment of intertriginous psoriasis. Br J Dermatol. 1996;135(4):647-650. 
  25. Duweb GA, Eldebani S, Alhaddar J. Calcipotriol cream in the treatment of exural psoriasis. Int J Tissue React. 2003;25(4):127-130. 
  26. Flytstrom I, Bergbrant IM, Brared J, Brandberg LL. Microorganisms in intertriginous psoriasis: no evidence of Candida. Acta Derm Venereol. 2003;83(2):121-123. 
  27. Hughes J, Rustin M. Corticosteroids. Clin Dermatol. 1997;15(5):715-721. 
  28. Zeichner JA. Use of Topical Coal Tar Foam for the Treatment of Psoriasis in Difficult-to-treat Areas. J Clin Aesthet Dermatol. 2010;3(9):37-40. 
  29. Carrascosa JM, Soria X, Domingo H, Ferrandiz C. Treatment of inverse psoriasis with excimer therapy and tacrolimus ointment. Dermatol Surg. 2007;33(3):361-363. 
  30. Mafong EA, Friedman PM, Kauvar AN, et al. Treatment of inverse psoriasis with the 308 nm excimer laser. Dermatol Surg. 2002;28(6):530-532. 
  31. Zanchi M, Favot F, Bizzarini M, et al. Botulinum toxin type-A for the treatment of inverse psoriasis. J Eur Acad Dermatol Venereol. 2008;22(4):431-436. 
  32. Saber M, Brassard D, Benohanian A. Inverse psoriasis and hyperhidrosis of the axillae responding to botulinum toxin type A. Arch Dermatol. 2011;147(5):629-630. 
  33. Menter A. Psoriasis and psoriatic arthritis treatment. Am J Manag Care. 2016;22(8 Suppl):s225-237. 
  34. Jese R, Perdan-Pirkmajer K, Dolenc-Voljc M, Tomsic M. A case of inverse psoriasis successfully treated with adalimumab. Acta Dermatovenerol Alp Pannonica Adriat. 2014;23(1):21-23. 
  35. Campos MA, Varela P, Baptista A, Moreira AI. Inverse psoriasis treated with ustekinumab. BMJ Case Rep. 2016;2016. 
  36. Nola I, Kostovic K, Kotrulja L, Lugovic L. The use of emollients as sophisticated therapy in dermatology. Acta Dermatovenerol Croat. 2003;11(2):80-87.
  37. Noah PW. The role of microorganisms in psoriasis. Semin Dermatol. 1990;9(4):269-276. 
  38. Rosenberg EW, Noah PW, Skinner RB, Jr., et al. Microbial associations of 167 patients with psoriasis. Acta Derm Venereol Suppl (Stockh). 1989;146:72-74; discussion 75. 
  39. Gudjonsson JE, Thorarinsson AM, Sigurgeirsson B, et al. Streptococcal throat infections and exacerbation of chronic plaque psoriasis: a prospective study. Br J Dermatol. 2003;149(3):530-534. 
  40. Leibovici V, Alkalay R, Hershko K, et al. Prevalence of Candida on the tongue and intertriginous areas of psoriatic and atopic dermatitis patients. Mycoses. 2008;51(1):63-66. 
  41. Vissers WH, Roelofzen J, De Jong EM, et al. Flexural versus plaque lesions in psoriasis: an immunohistochemical differentiation. Eur J Dermatol. 2005;15(1):13-17. 
  42. Jue SG, Dawson GW, Brogden RN. Ciclopirox olamine 1% cream. A preliminary review of its antimicrobial activity and therapeutic use. Drugs. 1985;29(4):330-341. 
  43. Farber EM, Nall L. Perianal and intergluteal psoriasis. Cutis. 1992;50(5):336-338. 
  44. Paek SY, Thompson JM, Qureshi AA, et al. Comprehensive Assessment of the Psoriasis Patient (CAPP): A Report from the GRAPPA 2015 Annual Meeting. J Rheumatol. 2016;43(5):961-964.

AUTHOR CORRESPONDENCE

Joseph F. Merola MD MMSc E-mail:................................................... [email protected]
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