The primary concerns for patients with palmar-plantar psoriasis are pain and discomfort. A randomized cross-sectional study surveyed 317 patients and found that patients with palmar-plantar psoriasis report more physical distress and disability than patients with plaque psoriasis (Pettey et al. 2003). Patients do not report significant psychosocial stress perhaps because the lesions are relatively easy to disguise. Yet, patients may avoid handshaking to prevent embarrassment (Pettey et al. 2003; Farley et al. 2009). For patients with palmar-plantar psoriasis, disease severity is considered a separate entity than the amount of body surface area affected (Farley et al. 2009). The palms and soles account for less than 5% of the total body surface area. However, patients report more functional disability than patients with psoriasis involving a greater body surface area (Ortiz et al. 2013; Pettey et al. 2003). Treatment should be aimed toward reducing pain and enhancing function even if palmoplantar lesions are not completely resolved (Pettey et al. 2003).

Mild cases of palmar-plantar psoriasis can be treated with topical corticosteroids alternating with topical vitamin D analogs (calcipotriene, calcitriol). Palmar-plantar psoriasis is characteristically difficult to treat, likely because the thickened stratum corneum acts as a barrier in preventing adequate percutaneous absorption. High-potency topical corticosteroids are more efficacious to try to penetrate the plaques. Occlusive methods may be utilized to help with absorption such as plastic wraps, gloves, and hydrocolloid occlusion.

For severe cases or cases with significant body surface area involvement, consider treatment with retinoids, methotrexate, or cyclosporine. Systemic medication is often limited to patients with over 10% body surface area. However, systemic medication should be considered for patients with palmar-plantar psoriasis because many cases are resistant to topical therapy and recurrence rates are high. Acitretin can decrease the severity of the painful lesions, which leads to patient satisfaction even though the lesions may not be completely resolved. The most common side effects seen with acitretin are the alterations in lipid levels and mucosal dryness (Ortiz et al. 2013). Since the side effects are dose-dependent, it is not necessary to increase the amount of systemic medication to completely resolve lesions if patients report an improvement in functional ability. A prospective randomized study compared methotrexate and acitretin and found both to significantly improve psoriatic lesions in both populations. Methotrexate may cause nausea and vomiting and changes in liver function tests, which are both reduced with daily folic acid supplementation (Janagond et al. 2013).

Apremilast and ustekinumab may also be used to treat palmar-plantar psoriasis (Pettey et al. 2003). Apremilast has been shown to improve palmar-plantar psoriasis at follow-up and was tolerated well with the most significant side effect of nasopharyngitis (Deeks 2015). Cyclosporine can provide the ability of patients to retain functional ability (Janegond et al. 2013). Cyclosporine is beneficial for highly resistant plaques or flares because it is fast acting. However, cyclosporine produces prominent side effects and is not suitable for chronic management of palmar-plantar psoriasis.