Validation and usability of modified palmoplantar psoriasis area and severity index in patients with palmoplantar psoriasis: A prospective longitudinal cohort study.

Background Palmoplantar psoriasis (PPP), a troublesome variant, does not have any validated scoring system to assess disease severity. Objective To validate modified Palmoplantar Psoriasis Area and Severity Index (m-PPPASI) in patients affected with PPP and to categorise it based on Dermatology Life Quality Index (DLQI). Methods In this prospective study, patients with PPP aged > 18 years visiting the psoriasis clinic at a tertiary care centre were included and requested to complete DLQI during each visit at baseline, 2nd week, 6th and 12th week. m-PPPASI was used by the raters to determine the disease severity. Results Overall, 73 patients were included. m-PPPASI demonstrated high internal consistency (α = 0.99), test-retest reliability of all three raters, that is, Adithya Nagendran (AN) (r = 0.99, p < 0.0001), Tarun Narang (TN) (r = 1.0, p < 0.0001) and Sunil Dogra (SD) (r = 1.0, p < 0.0001) and inter-rater agreement (intra-class correlation coefficient = 0.83). Face and content validity index for items I-CVI = 0.845 were robust, and the instrument was uniformly rated as easy to use (Likert scale 2) by all three raters. It was found to be responsive to change (r = 0.92, p < 0.0001). Minimal clinically important differences (MCID)-1 and MCID-2 calculated by receiver operating characteristic curve using DLQI as anchor were 2 and 35%, respectively. DLQI equivalent cutoff points for m-PPPASI were 0-5 for mild, 6-9 for moderate, 10-19 for severe, and 20-72 for very severe disease. Limitation Small sample size and single-center validation were the major limitations. m-PPPASI doesn't objectively measure all characteristics of PPP such as "fissuring" and "scaling" which could also be taken into consideration. Conclusion m-PPPASI is validated in PPP and can be readily utilized by physicians. However, further large-scale studies are needed.

Methotrexate monotherapy versus methotrexate and apremilast combination therapy in the treatment of palmoplantar psoriasis: A prospective, randomised, assessor-blinded, comparative study.

BACKGROUND: Palmoplantar psoriasis is a chronic debilitating condition which significantly impairs quality of life. OBJECTIVES: To assess the efficacy and safety of the combination of apremilast and methotrexate compared with methotrexate monotherapy in the treatment of palmoplantar psoriasis. Also, to study the impact on treatment on the Dermatology Life Quality Index and Palmoplantar Quality of Life Index. METHODS: A total of 64 patients were randomised to two groups in a 1:1 ratio - Group A received both methotrexate and apremilast in combination, while Group B received only methotrexate, for 16 weeks. The primary endpoints were the mean score of Modified Palmoplantar Psoriasis Area and Severity Index at week 16, the proportion of patients achieving modified palmoplantar psoriasis area severity index-75 and/or Palmoplantar Psoriasis Physician Global Assessment score 0/1 at week 16. RESULTS: A significantly higher proportion of patients in Group A achieved Modified Palmoplantar Psoriasis Area and Severity Index-75 at week 16 (43% in Group A vs 30% in Group B). The Modified Palmoplantar Psoriasis Area and Severity Index score was significantly lower in the combination group at week 16 (4.03 ± 2.05 in Group A and 5.89 ± 2.31 in Group B, P-value = 0.002). About 80% of patients in the combination group with baseline Palmoplantar Psoriasis Physician Global Assessment ≥3 achieved Palmoplantar Psoriasis Physician Global Assessment 0/1 compared to 60% in Group B. The combination group showed a significantly higher reduction in Dermatology Life Quality Index and Palmoplantar Quality of Life Index scores compared to the methotrexate alone group (P-value = 0.025). No notable adverse events were observed. LIMITATION: The limitations of the study were single blinding, small sample size and a lack of longer follow up to assess the rate of relapse. We did not account for attrition during sample size calculation. Also, due to the paucity of data regarding the use of apremilast in palmoplantar psoriasis, definitive comparisons could not be made with previous studies. CONCLUSION: The combination of apremilast and methotrexate has superior efficacy and a similar safety profile as compared to methotrexate monotherapy for the treatment of moderate to severe palmoplantar psoriasis.

Comparative therapeutic evaluation of different topicals and narrow band ultraviolet B therapy combined with systemic methotrexate in the treatment of palmoplantar psoriasis.

BACKGROUND: The incidence of uncomplicated psoriasis is 1-3% in the general population. The involvement of palm and sole is seen in 7-14.5% of cases. There are different topicals and systemic therapies available for treating the case of psoriasis but none is satisfactory for longer duration. AIM: The study involved the comparative therapeutic evaluation of the different topical regimens and narrow band ultraviolet B (NB-UVB) therapy in combination with systemic methotrexate. MATERIALS AND METHODS: The study was held in out-patient department of Skin, VD and Leprosy of B.R.D. Medical College, Gorakhpur, from July 2007 to December 2008. The group included 98 new cases of palmoplantar psoriasis. These cases were divided into eight groups according to the eight regimens involved in the study. The severity of psoriasis was assessed by the ESIF (erythema, scaling, induration and fissuring) score. RESULTS: The study showed that all the regimens had significant response rates. The combination of NB-UVB with systemic methotrexate had maximum response rate (64.85±4.52%) that was statistically significant (paired "t" at 16d.f. = 33.329, P<0.001) with minimum number of recurrences after stopping the treatment. The combination of halobetasol ointment with systemic methotrexate also had significant response rate (paired "t" at 19d.f. = 13.5183, P<0.001) but had maximum number of cases with recurrence (70%) after stopping the treatment. CONCLUSION: These results suggest that the combination of every regimen with systemic methotrexate resulted in an early and a good improvement in the quality of life of patients suffering from psoriasis. It also shows that NB-UVB in combination with systemic methotrexate is more efficacious and has minimum recurrence rate and side effects in the treatment of palmoplantar psoriasis.