Author: Hon Assoc Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, 1997. Reviewed and updated, September 2014.
Palmoplantar pustulosis is an uncommon chronic pustular condition affecting the palms and soles. It is also called pustulosis palmaris et plantaris. It is related to a common skin condition, psoriasis.
A variant of palmoplantar pustulosis affecting the tips of the digits is called acrodermatitis continua of Hallopeau or acropustulosis.
Palmoplantar pustulosis presents as crops of sterile pustules occurring on one or both hands and feet. They are associated with thickened, scaly, red skin that easily develops painful cracks (fissures).
Palmoplantar pustulosis varies in severity and may persist for many years. The discomfort can be considerable, interfering with work and leisure activities.
Certain manual occupations or occupations involving much walking are inadvisable for affected individuals.
Certain conditions have been reported to occur in patients with palmopustular pustulosis more often than in unaffected patients.
The exact cause of palmoplantar pustulosis is unknown. There have been several theories.
The majority of patients with palmoplantar pustulosis are current smokers and in those that have smoked in the past (65–90%). It is thought that activated nicotine receptors in the sweat glands cause an inflammatory process.
Palmoplantar pustulosis is generally diagnosed clinically.
Treatment of palmoplantar pustulosis does not cure the disorder and is not always successful. The following may be helpful.
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 clobetasol propionate 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 five days in a row.
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.
Acitretin tablets, derived from Vitamin A, can control palmoplantar pustulosis in the majority of users. They have some potentially serious side effects so are only suitable for significantly disabled patients. A newer retinoid, alitretinoin, may also be effective.
Narrowband UVB and photochemotherapy (the combination of exposure to ultraviolet radiation (UV-A) with psoralens taken as tablets or applied topically—bathwater PUVA—can be very effective. Careful supervision is necessary to avoid burning.
A variety of other medications can help some subjects including:
Although they sometimes induce palmoplantar pustulosis as a side effect of treatment, biologics are occasionally effective when used for severe palmoplantar pustulosis.
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