Reconsidering Psoriasis at High-Impact Locations

In a compelling session at the Masterclasses in Dermatology APP Institute, Cynthia Trickett, MPAS, PA-C, spotlighted the underappreciated burden of psoriasis in special sites, where surface area may be small, but the impact is huge.

“Site matters as much as severity in psoriasis management,” Trickett emphasized, urging providers to prioritize patient experience, not just body surface area (BSA) percentages, when making treatment decisions.

From folds and genitals to nails, scalp, and palms, these high-impact areas often correlate with functional impairment, social stigma, and psychological distress far beyond what is visible. Palmoplantar psoriasis has “greater disease impact and more missed work hours than plaque psoriasis,” Trickett said. “Much higher Dermatology Life Quality Index scores” are common in these patients.

Inverse psoriasis affects up to 30% of patients and is frequently misdiagnosed as a fungal infection. Moisture, friction, fissures, and erosions complicate treatment. Trickett emphasized the psychosocial weight of these cases, which “can affect intimacy, career choices, clothing selection, and hygiene practices,” advocating for normalization and permission-based exams.

In genital psoriasis, embarrassment and delays in care are common. Patients rarely volunteer symptoms unless prompted. “A social faux pas to scratch genitals in public!” Trickett quipped, underscoring the stigma.

Nail psoriasis affects up to 80% of patients with psoriatic arthritis, with pitting and onycholysis causing pain and embarrassment. When more than 3 nails are involved, or there is joint impact, Trickett recommends considering systemic therapy.

Scalp psoriasis is often the first manifestation of disease but commonly goes undiagnosed. Palmoplantar disease, while localized, drives significant disability, missed work, and disproportionately high quality-of-life burden.

Trickett highlighted the 2024 International Psoriasis Council criteria, which affirm that “involvement of high-impact sites such as inverse areas should prompt consideration of systemic therapy regardless of the affected BSA.”

She encouraged APPs to “document appropriately” and advocate for patients even when coverage doesn’t align with old metrics.

“Advocate for a patient-centered approach that accounts for and understands psychosocial burden,” Trickett concluded. Do not let small spots get small attention; these areas demand big consideration and a shift in mindset.

Reference

Trickett C. Psoriasis high impact sites: inverse, genital, scalp, nail, palmoplantar. Presented at: Masterclasses in Dermatology APP Institute; October 11–12, 2025; Dallas, TX.