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Biological drugs have dramatically changed the approach to treating moderate-to-severe plaque psoriasis, achieving excellent skin clearance and safety outcomes. However, the management of difficult-to-treat areas (e.g., scalp, palms/soles, nails, and genitalia) still represents a challenge in psoriasis treatment. Data in the literature on difficult-to-treat sites are limited and, frequently, no specific analysis is performed during clinical trials. We conducted a 52-week, retrospective study to evaluate the effectiveness of ixekizumab in 120 patients with moderate-to-severe plaque psoriasis of at least one difficult-to-treat area (scalp, palmoplantar surfaces, nails, and genitalia). Ninety-nine patients had scalp psoriasis, 35 had involvement of the palms or soles, 27 were affected by genital psoriasis, and 22 patients reported involvement of the nails. After 1 year of treatment, 96% of patients with scalp involvement, 95.6% of patients with palmoplantar psoriasis, 95.2% of patients with genital psoriasis, and 85% of patients with nail involvement achieved a site-specific Physician's Global Assessment of 0 or 1 (clear or almost clear). No serious adverse events were observed during the study. Our study supports the effectiveness of ixekizumab in plaque psoriasis involving difficult-to-treat sites.

The Wolf’s isotopic phenomenon corresponds to the occurrence of a skin disease at a body site affected previously by a different, already healed dermatosis. We report a 74-year-old man who presented with a zosteriform eruption consisting of erythematous-scaly, slightly pruritic papules on the right flank some weeks after herpes zoster (HZ) had healed on the same area. Histologic examination showed typical changes of lichen planus, confirming the diagnosis of post-HZ zosteriform lichen planus (ZLP). The lesions regressed with topical steroid treatment. Zosteriform lichen planus (ZLP) is one example of Wolf’s isotopic phenomenon appearing after HZ. So far, only 17 cases have been reported in the literature. The precise pathogenesis of ZLP is not well known, although persisting viral proteins could be responsible for the hypersensitivity reaction. We review and discuss the salient clinicopathologic features of this rare entity based on a thorough literature review.

The Wolf’s isotopic phenomenon corresponds to the occurrence of a skin disease at a body site affected previously by a different, already healed dermatosis. We report a 74-year-old man who presented with a zosteriform eruption consisting of erythematous-scaly, slightly pruritic papules on the right flank some weeks after herpes zoster (HZ) had healed on the same area. Histologic examination showed typical changes of lichen planus, confirming the diagnosis of post-HZ zosteriform lichen planus (ZLP). The lesions regressed with topical steroid treatment. Zosteriform lichen planus (ZLP) is one example of Wolf’s isotopic phenomenon appearing after HZ. So far, only 17 cases have been reported in the literature. The precise pathogenesis of ZLP is not well known, although persisting viral proteins could be responsible for the hypersensitivity reaction. We review and discuss the salient clinicopathologic features of this rare entity based on a thorough literature review.

This article provides comprehensive recommendations for the systemic treatment of severe pediatric psoriasis based on evidence obtained from a systematic review of the literature and the consensus opinion of expert dermatologists and pediatricians. For each systemic treatment, the grade of recommendation (A, B, C) based on the treatment’s approval by the European Medicines Agency for childhood psoriasis and the experts’ opinions is discussed. The grade of recommendation for narrow-band-ultraviolet B phototherapy, cyclosporine, and retinoids is C, while that for methotrexate is C/B. The use of adalimumab, etanercept, and ustekinumab has a grade A recommendation. No conventional systemic treatments are approved for pediatric psoriasis. Adalimumab is approved by the European Medicines Agency as a first-line treatment for severe chronic plaque psoriasis in children (≥ 4 years old) and adolescents. Etanercept and ustekinumab are approved as second-line therapy in children ≥6 and ≥ 12 years, respectively. Conclusion: A treatment algorithm as well as practical tools (i.e., tabular summaries of differential diagnoses, treatment mechanism of actions, dosing regimens, control parameters) are provided to assist in therapeutic reasoning and decision-making for individual patients. These treatment recommendations are endorsed by major Italian Pediatric and Dermatology Societies.