Dr. Tina Bhutani discusses highlights from her lecture, "Treating High-Impact Sites in Psoriasis," at the Grand Hyatt Deer Valley in Park City, Utah, at the 2nd Annual Elevate-Derm Alliance Summer Conference.

In this video

Speaking with dermatology PA Buchi Nita, Dr. Bhutani defines the high-impact sites—the face, intertriginous folds, genital skin, and palmoplantar disease—as areas that represent a small percentage of body surface area but carry a "high impact" on quality of life and are notoriously "difficult to treat." Because these sites sit in sensitive areas, patients often don't volunteer them, so she urges clinicians to ask directly and to periodically perform full-body skin exams rather than just refilling medications. She notes that involvement of special sites raises the risk of comorbidities like psoriatic arthritis, and that the International Psoriasis Council now lists special-site disease as a factor that makes patients candidates for systemic therapy—even at 1% BSA.

On documentation, she reminds clinicians that noting special-site involvement and quality-of-life impact can help push prior authorizations through when payers don't see the "magical 10% body surface area" number. She then walks through hands-on tactics: combination therapy and proper topical technique for the scalp (parting the hair to get medication onto the skin, overnight oil deep-treatments under a shower cap, salicylic acid and coal tar shampoos to loosen thick scale), and occlusion for palmoplantar disease using nitrile gloves overnight on the hands and Saran wrap or a disposable shower cap plus a sock on the feet, with topical retinoids added for their keratolytic, skin-thinning effect.

  • High-impact sites (face, folds, genitals, palms/soles) are low in BSA but high in quality-of-life burden—push to get these patients as clear as possible, as quickly as possible.
  • Ask about rashes in sensitive areas and do periodic full-body skin exams; don't just refill and send patients out the door.
  • Even at 1% BSA, special-site involvement now supports the conversation about systemic therapy per International Psoriasis Council guidelines—and raises psoriatic arthritis risk.
  • Documenting special-site involvement and quality-of-life impact can help prior authorizations go through when the 10% BSA threshold isn't met.
  • For scalp, part the hair to reach the skin and use overnight oil under a shower cap plus keratolytic shampoos; for palmoplantar disease, occlude with gloves or Saran wrap/shower cap and sock, and add a topical retinoid to thin thick skin.