Small surface exposure poses big issues
How to diagnose and manage difficult-to-treat skin conditions on hands and feet.
F074 – Challenging Skin Disorders of Hands and Feet
9-11 a.m. | Monday, March 30
Mile High 1D
Dermatologic disorders of the hands and feet create the perfect storm of biologic and practical treatment obstacles for patients and dermatologists alike. The diagnostic and therapeutic challenges represent just 4% of the body’s surface area yet have a significant impact on a patient’s quality of life, said Mark Lebwohl, MD, FAAD, professor of dermatology and chairman emeritus at the Icahn School of Medicine at Mount Sinai in New York.
Dr. Lebwohl is among a panel of dermatologists who will sift through the trials and available treatments during Monday’s session, F074 – Challenging Skin Disorders of Hands and Feet. The session will include a broader discussion of the clinical presentation and management of conditions, such as psoriasis, palmoplantar pustulosis, vitiligo, chronic hand eczema, recurrent actinic keratoses, and periungual warts, shedding new insight into the etiopathogenesis and therapies of each.
“Think about every time you go to shake someone’s hand, or [there’s] somebody working in a deli, and customers look at their hands; they don’t want [them] touching their food. Think about every time you button your shirt, and you get the ooze of eczema or cracking and bleeding from psoriasis or the pus of pustular psoriasis on your shirt. It has a disproportionate impact on your quality of life, not to mention the pain associated with it,” Dr. Lebwohl said.
Tough to crack
According to Dr. Lebwohl, the stubborn nature of such highly visible conditions in high impact areas — including painful manifestations like fissures, blisters, pustules, and erosions — commonly limits even basic tasks such as walking
or working.
One of the reasons these disorders remain difficult to diagnose and treat, he said, is because of physical features, such as a thickened stratum corneum on palms and soles. This significantly reduces the penetration of topical medications and is one reason why therapies are slower or less effective.
There are other reasons too, said session presenter Iltefat H. Hamzavi, MD, FAAD, a dermatologist with Henry Ford Hospital and Hamzavi Dermatology/Specialists in Detroit. This includes limited ability to regenerate pigment, especially in vitiligo affecting the fingertips, which stems from the scarcity of hair follicles that normally supply melanocytes.
“Another consideration is that many experts feel that periungual vitiligo puts you at much higher risk of developing facial vitiligo. And those are the two regional variations that have the greatest psychosocial impact,” Dr. Hamzavi said. “Managing one may help prevent it from occurring in the other location, but more evidence is needed.”
The current treatment landscape
In addition to vitiligo, other difficult-to-treat hand and foot dermatoses include hand eczema, psoriasis (more specifically, palmoplantar pustular psoriasis [PPPP]), and bullous pemphigoid, said Thierry Passeron, MD, PhD, professor and chair of dermatology at University Hospital of Nice in France. Fortunately, he said there are new treatments in development for many of these dermatoses.
“Some are already approved, such as for hand eczema. There are others with promising preliminary results and ongoing confirmatory trials, such as for palmoplantar pustular psoriasis,” Dr. Passeron said. “Unfortunately, in some diseases, such as vitiligo, hands and feet remain the most challenging areas, and further research is warranted to provide better care for those patients.”
Several ongoing phase 2 and 3 trials, including systemic and topical JAK inhibitors and anti IL-17A/F therapies for PPPP, are currently confirming early successes, Dr. Passeron said.
For hand eczema, Dr. Passeron said researchers have seen positive results with systemic drugs. More recently, a topical JAK inhibitor that demonstrated positive results is now FDA-approved for chronic hand eczema, he said.
“This is exciting and very encouraging for patients. Unfortunately, even with these new approaches, repigmentation of vitiligo on hands and feet (especially on the digits) remains very difficult,” Dr. Passeron said. “Periungual warts also remain very challenging to treat. For those disorders, new treatments are clearly needed.”
In addressing treatment for hand and foot vitiligo, Dr. Hamzavi emphasized the importance of early detection, aggressive management, and vigilance for periungual involvement. He has seen success with a combination of systemic immunosuppression, phototherapy two to three times a week, topical immunomodulators such as ruxolitinib or tacrolimus, and topical steroids.
An obscure outlook
Dr. Lebwohl said there’s a dramatic lag in treatments for hand psoriasis compared to body psoriasis and noted that some clinical trials show palms and soles taking years to respond to the same medications that improve trunk and limb disease within months.
Another concern, he said, is diagnostic uncertainty when skin disease is limited to the palms and soles. Dr. Lebwohl pointed to emerging molecular profiling tools that may help clinicians distinguish psoriasis from eczema, pustular variants, and other inflammatory disorders — potentially reducing misdiagnosis and guiding better therapy selection.
Although Dr. Lebwohl is hopeful about the future of managing hand and foot dermatoses, he also offers cautious optimism.
“There’s room for improvement,” he said. “Although major gaps remain, the expanding range of therapies and improved diagnostic tools offer hope that treatment for hand and foot disease will continue to advance.”
Monday’s panel will also include speakers Kendall Billick, MD, FAAD; Robert Bissonnette, MSc, MD, FAAD; Emma Guttman, MD, PhD, FAAD; Bruce Elliot Strober, MD, PhD, FAAD; and Rolf-Markus Szeimies, MD, PhD, IFAAD.
