Comparison of the Efficacy and Safety of Apremilast and Methotrexate in Patients with Palmoplantar Psoriasis: A Randomized Controlled Trial

Background Placebo-controlled studies have reported the efficacy of apremilast in the management of palmoplantar psoriasis but studies comparing efficacy with a conventional agent are lacking. Objective The objective of this article was to compare the efficacy and safety of apremilast and methotrexate in patients with palmoplantar psoriasis. Methods In this prospective, randomized, active-controlled, observer-blinded clinical trial, conducted at a psoriasis clinic of a tertiary care institute in India from 1 July, 2019 to 1 June, 2020, 84 patients with palmoplantar psoriasis were randomized (1:1) to receive either methotrexate (0.4 mg/kg/week orally) or apremilast (30 mg twice daily). The treatment protocol was continued for 16 weeks or until achieving a ≥ 75% improvement in the Modified Palmoplantar Psoriasis Area and Severity Index (m-PPPASI 75), whichever was earlier. Changes in m-PPPASI and Dermatology Life Quality Index scores from baseline, the proportion of patients achieving m-PPPASI 75, and adverse events were assessed. Results Eighty-four patients were included (76 palmoplantar psoriasis and 8 palmoplantar pustulosis). The mean age (standard deviation) was 44.5 (12.9) years and 53 (63%) were women. The m-PPPASI score [median (interquartile range)] after 16 weeks of treatment showed a significant improvement from baseline in both apremilast [− 6.3 (10.9), p < 0.001] and methotrexate groups [− 8.5 (9.9), p < 0.001]. The estimated median difference between the groups was − 1.2 ( p = 0.39, 95% confidence interval − 4.2 to 2.1). At 16 weeks, m-PPPASI 75 was achieved by 14/42 (33%) and 17/42 (41%) patients in the apremilast and methotrexate groups, respectively ( p = 0.49). A significant reduction in the Dermatology Life Quality Index score [median (interquartile range)] was observed in both groups [apremilast: − 3.0 (6.0), p < 0.001; methotrexate: − 3.0 (6.3), p < 0.001] with an estimated median difference of 0.0 ( p = 0.99, 95% confidence interval − 1.0 to 2.0). The proportion of patients experiencing adverse events was comparable ( p = 0.49). Conclusions Apremilast showed a comparable efficacy and safety profile to methotrexate in the management of palmoplantar psoriasis. Clinical Trial Registration CTRI/2019/06/019830, date of registration: 24 June, 2019; trial registered prospectively.