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Payton Smith,1 Allison Kranyak,1 Chandler E Johnson,1 Kathryn Haran,1 Isabel Muraguri Snr,2 Toby Maurer,3,4 Tina Bhutani,1 Wilson Liao,1 Samson Kiprono2,3 1Department of Dermatology, University of California at San Francisco, San Francisco, CA, USA; 2Department of Dermatology, Moi Teaching and Referral Hospital, Eldoret, Kenya; 3Department of Medicine Moi University, Eldoret, Kenya; 4Department of Dermatology, Indiana University, Indianapolis, IN, USACorrespondence: Payton Smith, University of California, San Francisco, Mount Zion Cancer Research Building, 2340 Sutter St., Box 0808, Floor 04, Room N426, San Francisco, CA, 94115, USA, Tel +1 415-944-7618, Email payton.smith@ucsf.eduIntroduction: Goeckerman therapy, which combines ultraviolet B (UVB) light with crude coal tar (CCT), remains highly effective for moderate-to-severe psoriasis. While it is rarely still used in the USA as effective biotherapeutics have become more readily available, it offers an alternative therapy in developing countries with limited access to newer medications. Moi Teaching & Referral Hospital (MTRH) in Eldoret, Kenya, in collaboration with UCSF, developed a modified Goeckerman regimen suitable for local healthcare needs, condensing the treatment into an intensive two-week program.Case Report: A 55-year-old female with erythrodermic psoriasis traveled 350 kilometers to MTRH. After the diagnosis was confirmed, she underwent a nine-day inpatient treatment with narrow-band UVB phototherapy and topical medications under occlusion as a modified Goeckerman regimen.Response to Treatment: Significant improvement was observed within three days, with full recovery in ten days. Follow-up one month later showed no active lesions, and her psoriasis remained controlled for four months with topical treatments.Conclusion: The modified Goeckerman regimen at MTRH, in collaboration with UCSF, effectively treated severe psoriasis in a challenging healthcare context. This case highlights the potential for adapting established treatments to improve patient outcomes in developing countries with limited access to systemic therapies.Keywords: Goeckerman therapy, erythrodermic psoriasis, UVB phototherapy, global health

Kathryn Haran,1,* Allison Kranyak,1,* Chandler E Johnson,2 Payton Smith,2 Aaron S Farberg,3,4 Tina Bhutani,1 Wilson Liao1,2 1Department of Dermatology, University of California San Francisco, San Francisco, CA, USA; 2Institute for Human Genetics, University of California San Francisco, San Francisco, CA, USA; 3Baylor Scott & White Health System, Dallas, TX, USA; 4Bare Dermatology, Dallas, TX, USA*These authors contributed equally to this workCorrespondence: Kathryn Haran, Department of Dermatology, University of California San Francisco, 2340 Sutter St N414, San Francisco, CA, 94115, USA, Tel +1 (415) 944-7618, Email Kathryn.haran@ucsf.eduAbstract: While psoriasis and atopic dermatitis (AD) are two common dermatological conditions, their diagnosis and therapeutic decision-making pathways are often complex. As a result, there has been increased focus on the development of precision medicine approaches for psoriasis and AD. Two companies at the forefront of dermatology precision medicine research are Mindera Health and Castle Biosciences. Here, we review the technologies developed by these two companies using a dermal diagnostic patch and superficial skin scrapings, respectively, their research published to date, and their future research goals. Research from both companies shows promise in predicting the response of inflammatory skin disease to biologics using minimally invasive techniques. However, challenges to adoption include insurance coverage and patient trust in the technologies. While there are several differences between Mindera Health and Castle Biosciences, they have a shared goal of utilizing minimally invasive technologies to sample skin and predict response to biologic treatments using a panel of optimized biomarkers.Keywords: machine learning, genetics, technology, diagnosis

Jason E Hawkes,1,* Dale V Reisner,2 Tina Bhutani3,* 1Department of Dermatology, University of California at Davis, Sacramento, CA, USA; 2Patient Author, Yankton, SD, USA; 3Psoriasis and Skin Treatment Center, Department of Dermatology, University of California at San Francisco, San Francisco, CA, USA*These authors contributed equally to this workCorrespondence: Tina Bhutani, Email tina.bhutani@ucsf.eduAbstract: Generalized pustular psoriasis (GPP) is a rare, chronic, and debilitating disease characterized by flares of widespread erythema, desquamation, and pustule formation. GPP flares can be accompanied by systemic symptoms including fever, fatigue, malaise, and skin pain; severe cases may be fatal if untreated. Although GPP may occur concurrently with plaque psoriasis, they represent two distinct inflammatory conditions. Patients with GPP experience a substantial burden of disease, and the impact of GPP on an individual’s mental health and quality-of-life (QoL) goes far beyond skin pain and discomfort. The rarity of GPP may result in a misdiagnosis, as the sudden onset of skin pustules may be mistaken for a primary infection. Misdiagnosis with a subsequent delay in treatment has tremendous negative consequences for the affected patient. In September 2022, spesolimab became the first FDA-approved medication in the US for the treatment of GPP flares in adults. Spesolimab has since been approved by regulatory agencies in numerous countries, including Japan, Mainland China, and the EU. Prior to spesolimab, the clinical management of GPP relied on the off-label use of systemic or biologic therapies approved for plaque psoriasis or other inflammatory conditions. There is a need for increased education among healthcare providers regarding the clinical diagnosis, risk stratification, and therapeutic management of this rare disease, including the other novel GPP-specific therapies in development. In this podcast, two dermatologists and a patient who has plaque psoriasis and GPP discuss the clinical presentation, symptoms, disease burden, QoL impacts, diagnostic challenges, and therapeutic strategies for the management of GPP.Keywords: generalized pustular psoriasis, GPP, pustules, quality-of-life, IL-36, spesolimab, plaque psoriasis, inflammatory skin disease

Riley K Spencer,1,2 Joy Q Jin,2,3 Kareem G Elhage,2 Mitchell S Davis,2 Wilson Liao,2 Tina Bhutani2 1Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA; 2Department of Dermatology, University of California at San Francisco, San Francisco, CA, USA; 3School of Medicine, University of California at San Francisco, San Francisco, CA, USACorrespondence: Riley K Spencer, Department of Dermatology, University of California at San Francisco, Box 1212, Floor 01, Room 101, 2340 Sutter Street, San Francisco, CA, 94115, USA, Tel +1 480 415 7224, Fax +1 415 502 4126, Email rileykylespencer@gmail.comAbstract: Topical medications represent the most commonly used drugs in the treatment of psoriasis. However, topical steroids are mainly limited to short-term or intermittent use, and traditional non-steroidal topicals such as vitamin D analogues, topical calcineurin inhibitors, and topical retinoids are limited by low efficacy and poor local skin tolerability. Tapinarof (GSK2894512, DMVT-505) is a novel, topical aryl hydrocarbon receptor (AHR) agonist, which was recently approved by the FDA for the treatment of plaque psoriasis in adults. Tapinarof acts to improve psoriasis through diminished IL-17A production by CD4+ T cells, increased barrier gene expression in keratinocytes, and reduced production of reactive oxygen species. Both short-term and long-term efficacy and safety have been evaluated in two Phase II and two Phase III (PSOARING 1 and 2) clinical trials in addition to a long-term extension study (PSOARING 3). Overall, the drug has shown beneficial effects in achieving clear skin in adults with moderate-to-severe psoriasis, good local tolerability, and also a long duration of effect even after discontinuation of the drug. Therefore, this therapy provides a new, highly effective and safe non-steroidal option to add to our psoriasis treatment toolbox for both initial clearance and long-term maintenance of disease.Keywords: tapinarof, vtama, psoriasis, PSOARING

Tina Bhutani,1,* Jason E Hawkes2,* 1Psoriasis and Skin Treatment Center, Department of Dermatology, University of California at San Francisco, San Francisco, CA, USA; 2Department of Dermatology, University of California at Davis, Sacramento, CA, USA*Both authors contributed equally to this paperCorrespondence: Dr. Jason E Hawkes, Email hawkes3@gmail.comAbstract: Generalized pustular psoriasis is a rare presentation of psoriatic disease and is characterized by the acute onset of diffuse superficial pustules on the skin. These pustules can often coalesce, forming what’s known as ‘lakes of pus’ that are most often seen on the trunk and on skin folds. GPP flares are often accompanied by systemic symptoms, including fever, malaise, and edema. The interleukin (IL)-36 pathway plays a central role in the development of GPP, although several other genes may be associated. The rarity of GPP makes its diagnosis challenging and it could be mistaken for an infectious condition or other types of pustular psoriasis, including unstable forms of plaque psoriasis that may present with pustules. Performing a thorough skin examination and obtaining a detailed history are vital to exclude these differential diagnoses. Incorrect or late diagnosis, inadequate or delayed treatment, and lack of specialist referrals may contribute to increased disease severity and can have a debilitating impact on patients’ quality of life. In this podcast, two US-based dermatologists discuss the clinical characteristics of GPP, highlight the central role of IL-36 in immunopathogenesis, and share practical approaches to recognizing and diagnosing the disease.Keywords: Diagnosis, generalized pustular psoriasis, genetics, immunopathogenesis, interleukin-36 pathway, quality of life

Samuel Yeroushalmi, Marwa Hakimi, Mimi Chung, Erin Bartholomew, Tina Bhutani, Wilson Liao Department of Dermatology, University of California, San Francisco, CA, USACorrespondence: Wilson Liao, Email wilson.liao@ucsf.eduAbstract: Psoriasis is a prevalent inflammatory skin disorder that is associated with a number of comorbidities including cardiovascular disease and metabolic syndrome. Exercise can influence the outcomes of chronic inflammatory diseases, and the presence of these diseases can also influence physical activity in afflicted patients. We reviewed the available literature published on exercise in psoriasis patients and aimed to explore physical activity levels, barriers to exercise, physical fitness, exercise as a prevention strategy as well as a treatment modality. Overall, patients with moderate to severe psoriasis are more sedentary than the general population and experience barriers to exercise secondary to their skin disease. Moderate to vigorous exercise may be an independent preventative factor in reducing the incident risk of developing psoriasis and the utilization of exercise as a weight loss strategy may improve disease severity especially in overweight patients. Expert panels agree that exercise can be beneficial as an adjunct treatment in patients with psoriasis who are overweight; however, more randomized clinical trials are needed to establish these links.Keywords: physical activity, weight loss, lifestyle

Mimi Chung, Erin Bartholomew, Samuel Yeroushalmi, Marwa Hakimi, Tina Bhutani, Wilson Liao The University of California, San Francisco, Department of Dermatology, San Francisco, CA, USACorrespondence: Mimi Chung, 515 Spruce Street, San Francisco, CA, 94118, USA, Tel +415-944-7618, Email mimi.chung244@gmail.comAbstract: Nutrition is a complex topic encompassing diet and a variety of supplements including vitamins, fish oil, herbal products, and probiotics. Patients with psoriasis display high interest in understanding the potential impact of nutritional modifications on their psoriasis. In this review, we examine the evidence for nutritional interventions in psoriasis and summarize important concepts. We found that certain diets, such as low-calorie diets for obese patients, gluten-free diets for patients with comorbid celiac disease, and the Mediterranean diet, may have benefits for psoriasis patients. Supplements in general do not show strong evidence of benefit, though more studies are required given the heterogeneity of these trials. Finally, the gut microbiome has drawn considerable interest in recent years, with specific probiotics showing promising results for psoriasis patients and warranting further exploration.Keywords: nutrition, supplements, probiotics, inflammatory skin disease

Vidhatha Reddy,1 Bridget Myers,1 Eric J Yang,2 Tina Bhutani1 1University of California, San Francisco, Department of Dermatology, San Francisco, CA, USA; 2Virginia Mason Medical Center, Seattle, WA, USACorrespondence: Vidhatha ReddyUniversity of California, San Francisco, Department of Dermatology, 515 Spruce Street, San Francisco, CA 94118, USAEmail Vidhatha.reddy@ucsf.eduAbstract: Halobetasol propionate and tazarotene lotion 0.01%/0.045% (HP/TAZ) is a topical medication approved for the treatment of plaque psoriasis in adults. As a treatment modality, HP/TAZ has a combinatory therapeutic effect because it contains both a corticosteroid (HP) and a retinoid (TAZ) component. Here, we review the important clinical efficacy and safety data derived from pivotal clinical trials for HP/TAZ in the treatment of plaque psoriasis. We also discuss the mechanism of action, dosage guidelines, pharmacokinetics/pharmacodynamics, and clinical considerations for HP/TAZ, including why HP/TAZ should be avoided in pregnant patients.Keywords: halobetasol propionate, tazarotene, Duobrii, psoriasis, plaque, topical

Mary Patricia Smith, Karen Ly, Quinn Thibodeaux, Tina Bhutani, Wilson Liao, Kristen M BeckDepartment of Dermatology, University of California, San Francisco, CA, USAAbstract: Acrodermatitis continua of Hallopeau (ACH) is a rare, sterile pustular eruption of one or more digits. The condition presents with tender pustules and underlying erythema on the tip of a digit, more frequently arising on a finger than a toe. As far as classification, ACH is considered a localized form of pustular psoriasis. The eruption typically occurs after local trauma or infection, but such a history is not always present and various other etiologies have been described including infectious, neural, inflammatory, and genetic causes. The natural progression of ACH is chronic and progressive, often resulting in irreversible complications such as onychodystrophy that can result in anonychia, as well as osteitis that can result in osteolysis of the distal phalanges. Because of the rarity of ACH, there have been no randomized controlled studies to evaluate therapies, resulting in an absence of standardized treatment guidelines. In clinical practice, a wide variety of treatments have been attempted, with outcomes ranging from recalcitrance to complete resolution. In recent years, the introduction of biologics has provided a new class of therapy that has revolutionized the treatment of ACH. Specifically, rapid and sustained responses have been reported with the use of anti-tumor necrosis factor agents like infliximab, adalimumab, and etanercept; IL-17 inhibitors like secukinumab; IL-12/23 inhibitors like ustekinumab; and IL-1 inhibitors like anakinra. Nevertheless, there remains a considerable need for more research into treatment for the benefit of individual patients with ACH as well as for the clinical knowledge gained by such efforts. The purpose of this review is to provide a comprehensive overview of the key features of ACH as well as a discussion of clinical management strategies for this unique and debilitating condition.Keywords: acrodermatitis continua of Hallopeau, psoriasis, pustular psoriasis, generalized pustular psoriasis, palmoplantar pustulosis

Karen Ly,* Kristen M Beck*, Mary P Smith, Quinn Thibodeaux, Tina BhutaniDepartment of Dermatology, University of California, San Francisco, CA, USA*These authors contributed equally to this work Abstract: Generalized pustular psoriasis (GPP) is a rare and potentially life-threatening variant of psoriasis that is characterized by recurrent, acute onset, widely distributed pustular eruptions on inflamed, erythematous skin. It is important to recognize acute GPP as a subtype of psoriasis associated with high morbidity and mortality so therapy can be initiated without delay. Since GPP was first described in 1910 by Leopold von Zumbusch, it has been inconsistently defined, stratified, and diagnosed in the literature. Multiple definitions and diagnostic criteria have been proposed over the years. Recently, formal consensus guidelines on GPP have been published by international groups. This article reviews the current evidence and understanding in the diagnosis and screening of GPP.Keywords: generalized pustular psoriasis, acute generalized pustular psoriasis of von Zumbusch, pustular psoriasis, diagnostic criteria

Mary Patricia Smith,1 Karen Ly,1 Quinn Thibodeaux,1 Tina Bhutani,1 Mio Nakamura21Department of Dermatology, University of California San Francisco, San Francisco, CA, USA; 2Department of Dermatology, University of Michigan, Ann Arbor, MI, USAAbstract: Vitiligo is a chronic autoimmune condition involving selective dysfunction and destruction of melanocytes in the skin, hair, or both. The typical presentation is well-demarcated depigmented skin patches. Given vitiligo is the most common cause of depigmentation worldwide and early disease responds best to treatment, prompt diagnosis and proactive management of vitiligo are critical. While a wide variety of treatments has demonstrated variable effectiveness in treating vitiligo, phototherapy remains standard of care because of its proven efficacy and favorable side effect profile. However, many patients with vitiligo are unable to access affordable, consistent, or convenient phototherapy. To address these issues, home-based phototherapy has emerged as a patient-centered alternative. The purpose of this review is to discuss management of vitiligo with a specific focus on access to home-based phototherapy (HBPT) for patients with this condition. Key challenges to HBPT include misperceptions around safety and efficacy, inadequate physician education and training, insurance and financial barriers, and appropriate patient selection. Solutions to these challenges are presented, such as approaches to improve physician education and increasing the evidence surrounding the effectiveness and safety of this treatment for vitiligo. In addition, various practical considerations are discussed to guide dermatologists on how to approach HBPT as a treatment option for patients with vitiligo.Keywords: vitiligo, pigmentation disorders, phototherapy, photomedicine

Sahil Sekhon, Caleb Jeon, Mio Nakamura, Di Yan, Ladan Afifi, Tina Bhutani, Ethan Levin Department of Dermatology, University of California, San Francisco, San Francisco, CA, USA Abstract: Psoriasis vulgaris is a chronic, immune-mediated systemic disease that affects ~7.5 million people in the US. It can be treated with many therapies, often in combination, which include topicals, phototherapy, oral systemics, and biologics. Biologic agents target specific components of the immune system involved in the pathogenesis of psoriasis including TNF-alpha, IL-12, IL-17, and IL-23. The biologic ixekizumab, approved for the treatment of moderate–severe plaque psoriasis in the US, targets IL-17. This review describes the role of IL-17 in psoriasis, the mechanism by which ixekizumab targets this cytokine, and the clinical utility of ixekizumab. Keywords: ixekizumab, biologics, psoriasis, IL-17, anti-IL-17

Michael Abrouk,1 Ethan Levin,2 Merrick Brodsky,1 Jessica R Gandy,1 Mio Nakamura,2 Tian Hao Zhu,3 Benjamin Farahnik,4 John Koo,2 Tina Bhutani2 1Irvine School of Medicine, Irvine, 2Department of Dermatology, Psoriasis and Skin Treatment Center, University of California, San Francisco, 3Department of Dermatology, University of Southern California Keck School of Medicine, Los Angeles, CA, 4Department of Dermatology, University of Vermont College of Medicine, Burlington, VT, USA Introduction: The 308 nm excimer laser is a widely used device throughout the field of dermatology for many diseases including psoriasis. Although the laser has demonstrated clinical efficacy, there is a lack of literature outlining the safety, efficacy, and patient acceptability of the excimer laser. Methods: A literature search on PubMed was used with combinations of the terms “excimer”, “excimer laser”, “308 nm”, “psoriasis”, “protocol”, “safety”, “efficacy”, acceptability”, “side effects”, and “dose”. The search results were included if they contained information pertaining to excimer laser and psoriasis treatment and description of the safety, efficacy, and patient acceptability of the treatment. Results: The 308 nm excimer laser is generally safe and well tolerated with minimal side effects including erythema, blistering, and pigmentary changes. It has a range of efficacies depending on the protocol used with several different treatment protocols, including the induration protocol, the minimal erythema dose protocol, and the newer minimal blistering dose protocol. Conclusion: Although the excimer laser is not a first-line treatment, it remains an excellent treatment option for psoriasis patients and has been demonstrated to be an effective treatment with little to no side effects. Keywords: excimer, laser, 308 nm, psoriasis, safety, efficacy

Benjamin Farahnik,1 Viraat Patel,2 Kourosh Beroukhim,3 Tian Hao Zhu,4 Michael Abrouk,2 Mio Nakamura,5 Rasnik Singh,3 Kristina Lee,5 Tina Bhutani,5 John Koo5 1University of Vermont College of Medicine, Burlington, VT; 2School of Medicine, University of California, Irvine, 3David Geffen School of Medicine, University of California, Los Angeles, 4University of Southern California Keck School of Medicine, Los Angeles, 5Department of Dermatology, Psoriasis and Skin Treatment Center, University of California, San Francisco, CA, USA Background: The efficacy and safety of biologic and phototherapy in treating moderate-to-severe psoriasis is well known. However, some patients may not respond well to biologic agents or phototherapy on their own and may require combination therapy. Skillfully combining a biologic agent and phototherapy may provide an additive improvement without much increase in risks.Objective: To summarize the current state of evidence for the efficacy and safety of combining biologics with phototherapy in the treatment of moderate-to-severe plaque psoriasis.Methods: We conducted an extensive search on Pubmed database for English language literature that evaluated the use of a combination of biologic and phototherapy for the treatment of moderate-to-severe psoriasis through January 2016. The search included the following keywords: psoriasis, etanercept, adalimumab, infliximab, ustekinumab, biologics, phototherapy, and combination therapy.Results: The primary literature included randomized controlled trials, a head-to-head study, open-label controlled and uncontrolled trials, case series, and case reports. Etanercept was used in over half of the reported cases, but other biologic agents used included ustekinumab, adalimumab, and infliximab. The vast majority of phototherapy was narrowband ultraviolet B (NBUVB) radiation. Most cases reported enhanced improvement with combination therapy. Serious adverse events throughout the study duration were reported in