Palmoplantar and nail psoriasis

Author: Clin Assoc Prof Amanda Oakley

Learning objectives
Clinical features
Differential diagnosis
Investigations
Management
Activity

Learning objectives

Note. You should have already read the overview page about psoriasis.

Clinical features

Psoriasis affecting the dorsal or ventral surfaces of the hands and feet may resemble psoriasis in other sites, with well demarcated erythematous scaly plaques. Fissuring can be troublesome.

There are also distinct subtypes of palmoplantar psoriasis.

Palmoplantar keratoderma
Keratoderma refers to chronically thickened palms and soles and may be due to various inherited keratin gene disorders and acquired diseases. Psoriatic keratoderma is recognised by:

Nail psoriasis
Nails may be the only site affected by psoriasis and is frequently mistaken for onychomycosis (fungal infection), with which it may coexist. It is particularly common in those with psoriatic arthritis affecting the digits. It is usually asymptomatic but may be painful. It is very persistent and resistant to treatment, because it takes a year or so for new cells produced at the matrix to reach the distal edge of the nail plate. Signs affecting one or more nails may include:

The nail psoriasis index was devised to evaluate the signs of nail psoriasis in each nail separately, each on a 1-3 scale: pitting, Beau's lines, subungual hyperkeratosis and onycholysis in the matrix, the subungual tissues distal to the lunula, or the whole nail unit.

Localised pustular psoriasis
Localised pustular psoriasis affects one or both palms and/or feet. When it arises in the absence of psoriasis elsewhere, it may be called ‘palmoplantar pustulosis’.

Acrodermatitis continua of Hallopeau
Acrodermatitis continua of Hallopeau is a chronic recurrent pustulation of nail folds, nail bed and distal fingers leading to loss of nails. it may occur alone or in association with chronic plaque psoriasis, psoriatic arthropathy, palmoplantar pustulosis and/or generalised pustular psoriasis.

Differential diagnosis

Palmoplantar psoriasis may be confused with:

Localised pustular psoriasis may be confused with:

Investigations

Investigations indicated in palmoplantar psoriasis may include:

Management

Mild palmoplantar plaque psoriasis is usually managed with topical agents.

Keratoderma is unresponsive to topical steroids and calipotriol. Use emollients that incorporate keratolytic agents such as 5% salicylic acid or up to 40% urea (e.g. heel balm).

Nail psoriasis is very refractory to treatment. Very patient subjects may see results from calcipotriol or fluororuacil solution applied to nail folds and hyponychium twice daily for at least 12 months. Injected triamcinolone acetonide is rarely used because of pain and the potential to cause atrophy. Systemic therapy may be helpful but is rarely warranted for nail disease in the absence of troublesome psoriasis elsewhere.

Palmoplantar pustulosis is usually initially managed with intermittent ultrapotent topical steroids (continuous treatment aggravates the condition), crude coal tar ointment, and/or emollients.

If palmoplantar psoriasis is severe and interferes with function (painful to walk or work), refer to a dermatologist. Do not prescribe oral corticosteroids as these often make the condition worse and more difficult to control by other means. Possible treatments include:

Activity

Provide advice about footwear for a patient with plantar psoriasis.

 

Page 5 of 9. Next topic: Topical therapy for psoriasis. Back to: Scaly skin diseases contents.

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