Combination treatment with a tumour necrosis factor antagonist and an oral retinoid: efficacy in severe acral psoriasis?

Abstract

Funding sources: none. Conflicts of interest: J.R.I., none declared; A.V.A. has received departmental research funding from Leo Pharma, Abbott and Schering Plough; V.P. has received departmental educational grants from MSD (Merck), Janssen and Basilea. Madam, Acral skin conditions have a particularly high impact on quality of life due to both functional impairment and their effect on cosmesis. We report a case of severe, treatment‐resistant, chronic acral psoriasis that responded to a combination of infliximab and acitretin therapy. Our patient was a 16‐year‐old, otherwise healthy, nonsmoking boy with no relevant family history who presented with well‐demarcated erythematous scaly plaques predominantly affecting the hands and feet (Fig. 1a–d), as well as the scalp. There was extensive nail involvement with onycholysis and pitting but skin pustules were absent and his joints were unaffected. A diagnosis of acral psoriasis was made based on the clinical features. His Psoriasis Area and Severity Index (PASI) was 8·2, reflecting the localized nature of his psoriasis. In contrast, his Dermatology Life Quality Index (DLQI) score was 16, demonstrating a very large impact on quality of life.1 This disparity is frequently observed for acral skin disease.2 The acral distribution was particularly disabling for our patient because he was a keen guitarist and racquet sports player and was undertaking written examinations. He had begun to wear a pair of black gloves whenever possible and his loss in confidence was reflected by avoidance of eye contact during consultations.