The Challenges of Managing Psoriasis on the Ear

Dear Editor:

Psoriasis, a common inflammatory skin condition, can affect specific body sites or affect the entire skin surface. Managing certain areas such as the face, genitalia, palms, and soles of the feet poses a particular challenge. Even when psoriasis is limited and localized, with a low Psoriasis Area and Severity Index (PASI), it significantly compromises patients’ quality of life. Consequently, systemic therapy can be necessary and endorsed.¹ However, should we include other anatomical regions in this list of the difficult-to-treat areas? Psoriasis can, not infrequently, affect the ear structures, also as the only localization (Figure 1). It may affect all ear components, from the auricle to the external auditory tract, the middle and inner ear. Itching and/or pain are often severe and distressing. Visible scales can lead to social embarrassment. Some studies indicate that ear psoriasis may even impair auditory function, causing chronic conductive and/or sensorial deafness, even dizziness is possible due to the involvement of cochlea.² In addition, another uncommon complication of ear psoriasis is external otitis, which should be considered also as a possible differential diagnosis beyond seborrheic dermatitis and eczema.³ Thus, while the PASI may not be markedly high, the Dermatology Life Quality and Severity Index (DLQI) is often significantly elevated.

FIGURE 1.

A and C) Severe psoriasis involving the external ear in 22-year-old female patients and a 53-year-old male patient. Lesions also affected the auditory tract and patients complained of pruritus and referred auditory symptoms. No other skin lesions were presented; B) Same female patient after 16 weeks of treatment with tildrakizumab, an IL-23 inhibitor; D) Improvement in the male patients after 16 weeks of treatment with ixekizumab, an IL-17 inhibitor

The therapeutic approach for ear psoriasis can be tricky. Topical ointments or foam are often poorly tolerated, leading to reduced treatment adherence.⁴ The chronic nature of the condition requires frequent applications, with potential local side effects such as skin atrophy and infections. In these cases, a systemic approach should be considered, despite the limited extent of the disease. Systemic treatments encompass both traditional agents like methotrexate and cyclosporine, as well as innovative drugs, including small molecules and monoclonal antibodies. Among the latter, interleukin (IL)-17 and IL-23 antagonists are particularly promising. In conclusion, psoriasis localized in the ear remains a neglected area in current medical understanding. Despite its limited spread, it significantly impacts quality of life. In certain conditions, PASI is not a complete and reliable scoring tool, instead DLQI should have a greater importance. We suggest that severe psoriasis involving the ear can be an indication for systemic therapies. Moreover, specific rating score should be employed. For example, a Physician Global Assessment (PGA), specific for the genitalia already exist. We propose that specific PGA also for ear psoriasis should be available. Other issues deal with the difficulty to visualize the inner ear structures; thus, the cooperation of other specialists becomes important. Eventually, more studies are imperative to correctly score ear psoriasis, evaluate possible hear problems and to assess the efficacy, safety, and tolerability of systemic treatments in addressing this specific type of psoriasis.