Dealing with Difficult or Unique Psoriasis Cases, with Douglas DiRuggiero, DMSc, MHS, PA-C

Douglas DiRuggiero, DMSc, MHS, PA-C, a certified physician assistant who is known for his clinical experience in dermatology, spoke at the 2025 New Wave Dermatology Conference about tips for healthcare providers in dealing with difficult psoriasis cases.

The interview, conducted by the HCPLive editorial team, features a discussion regarding such cases, advice from DiRuggiero on how to deal with said cases, and additional information related to psoriasis management. DiRuggiero also provided specific examples of such cases to highlight real-world evidence for those interested in such advice.

“When I approach a patient that I think has psoriasis, the first tip is to make sure that it is psoriasis, and that's because successful treatments are always gonna be targeted towards the right diagnosis,” DiRuggiero explained. “...Part of my session that I presented at the beginning was looking at some very unusual presentations of psoriasis with a plaque that has central clearing, what we call ‘annular psoriasis.’ A very unusual presentation.”

DiRuggiero noted that once a diagnosis is determined, an assessment of other co-morbid conditions is needed, with examples such as joint involvement or GI involvement being given. If a patient had inflammatory bowel disease, for example, DiRuggiero noted that such a case may require avoidance of a certain class of therapeutics for such a reason.

“So right up front, I give them hope that we can choose a multitude of products that we think will get them almost all the way clear and keep them clear almost all the time,” DiRuggiero said. “Then we started going through some questions and talking about the different classes of monoclonal antibodies or oral treatments that are out, that are systemic, to try to really get them the clearance and improvement in their skin, or their skin and joints, that they would they would want to have.”

Later, DiRuggiero was asked to provide specific examples of such cases and asked about the management of these patients’ psoriasis.

“Some unique cases would be based on severity,” DiRuggiero explained. “[For] someone who comes in with almost 90% body surface area covered, what do you do with a patient like that? Again, it's giving them hope and saying that we've got systemic therapies that can be very, very helpful. Unique cases [could also be] patients who present with pretty significant joint problems, where they already have two sausage digits or dactylitis, and have psoriatic arthritis and psoriasis.”

Other examples of unique cases highlighted in this interview included severe cases with small levels of BSA but located in high-impact areas such as the genitalia or scalp.

“I presented a case that was in literature, not my case, of a woman who had crusted, Norwegian scabies that was being mistreated as psoriasis,” DiRuggiero said. “It looked like psoriasis. You looked at photographs…it had thick plaques on the chest. So that was one where you had to put on your thinking cap, so to speak.”

For additional information related to this topic, view the full video segment posted above.

The quotes used in this interview summary were edited for clarity.