Treatment of pityriasis rubra pilaris in adults

IL: interleukin; TNF: tumor necrosis factor; IVIG: intravenous immunoglobulin.
* Data are insufficient regarding the relative efficacy of these therapies. Selection is based upon patient comorbidities, drug availability, and patient preference. A biologic IL-17 or IL-23 inhibitor is our preferred initial therapy. We prescribe retinoid therapy (typically isotretinoin) for patients who cannot receive biologic therapy and prescribe methotrexate for patients who cannot receive biologic or retinoid therapy.
¶ Topical emollient ointments or creams, such as petrolatum or a bland, cream-based emollient, can be applied multiple times daily, as needed for comfort. A medium-potency topical corticosteroid should be applied daily and discontinued after 2 weeks if there is no improvement. Low-potency topical corticosteroids are preferred for facial and intertriginous skin.
Δ The addition of an oral retinoid (typically isotretinoin) or methotrexate to biologic therapy is an option for patients with a partial response to biologic therapy. We tend to add an oral retinoid or methotrexate when improvement of palmoplantar keratoderma lags behind improvement of other body areas.
◊ For patients who had a partial response to the oral retinoid or methotrexate, the oral retinoid or methotrexate can be continued during biologic therapy, with the goal of stopping the retinoid or methotrexate as improvement occurs with biologic therapy.