Palmoplantar pustulosis

Palmoplantar pustulosis affects the palms and soles. It is also known as localised pustular psoriasis, especially when in occurs in those who have psoriasis elsewhere.

It is much more common in those who smoke (or have smoked in the past), sometimes runs in families and rarely occurs before adulthood.

Some affected persons also have plaque psoriasis. dermatitis and tinea pedis (a fungus infection) may appear similar, but require different treatment.

Palmoplantar pustulosis

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Clinical features

Groups of sterile pustules occur in crops on one or both hands and/or feet. They are associated with thickened, scaly, red skin which easily develops painful cracks (fissures).

The condition varies in severity and may persist for many years. It is not known what causes exacerbations or remissions. Palmoplantar pustulosis is not infectious to other people and does not influence one's general health. However the discomfort can be considerable, interfering with working and leisure activities.

Walking for prolonged periods may cause exacerbations on the feet. If the palms are involved, manual activities may be uncomfortable, and injuries may aggravate the disorder. Certain occupations are therefore inadvisable for affected individuals.

Treatment

Treatment does not cure the disorder, but the symptoms can usually be controlled with the following measures.

General Measures

• Choose comfortable footwear made from natural fibres.
• Avoid friction and minor injuries.
• Cover deep fissures with a waterproof dressing.
• Rest the affected area.

Emollients

• Use plenty of grease or other thick emollient to soften the dry skin to prevent fissures.
• Soak in warm water with emulsifying ointment for 10 minutes.
• Apply white soft paraffin liberally
• Use salicylic acid ointment or urea cream (heel balm) to peel off dead skin (may sting).
• Wash with bath oil or soap substitute.

Topical Steroids
Topical steroids are anti-inflammatory agents which range in potency and vehicle. Only the strongest ointments are effective in conditions affecting the thick skin of the hands and feet. However the very potent products such as clobetasone proprionate should be used only for limited periods or else side effects and loss of efficacy become a problem.

A thin smear should be applied twice daily to the affected area. The effect may be enhanced by using plastic occlusion for a few hours or even overnight - use polythene gloves, plastic bags or cling film. Do not use occlusion for more than 5 days in a row.

Coal Tar
Crude coal tar is very messy but applied directly to the pustules every five days or so can stop them occurring. Paint on carefully and cover. It can be mixed in an ointment base for easier application.

Vitamin-D derivatives
Calcipotriol ointment is a vitamin-D derivative which is applied twice daily. It is effective in some patients with psoriasis. It should not be covered. Take care not to get the ointment on your face; wash your fingers after applying it to the affected areas. If helpful, keep applying it twice a day.

Acitretin
Acitretin tablets, derived from Vitamin A, can control palmoplantar pustulosis in the majority of users. They have a number of potentially serious side effects so are only suitable for significantly disabled patients.

PUVA
Ultraviolet radiation, especially in combination with psoralens taken as tablets or applied topically, can be very effective (PUVA). Careful medical supervision is necessary to avoid burning.

Other
A variety of other medications can help some subjects including:

• Colchicine
• Dapsone
• Methotrexate
• Tetracycline antibiotics