Palmoplantar Pustulosis

Palmoplantar (Palmo, meaning palm, plantar meaning sole of the foot) pustulosis is a persistent (chronic) condition that causes blisters filled with fluid on the palms and the soles of the feet. It can sometimes occur with the skin condition psoriasis. 

Palmoplantar pustulosis is an auto-inflammatory disease, but the exact cause of the condition is still not fully understood. It is a form of psoriasis, and up to 24% of patients also have psoriasis on other body parts. Some people with palmoplantar pustulosis also have family members with psoriasis. 

Smoking is one of the most important precipitating factors for the development of palmoplantar pustulosis, and studies show that up to 95% of people with the skin condition smoke or once did.

Several other reasons are known, making some people more likely than others to be affected; these include metal sensitivities (mainly nickel), infections, trauma, stress, and some medications.

Some psoriasis treatments known as TNF-alpha antagonists may occasionally trigger palmoplantar pustulosis. However, many other treatments for psoriasis do improve palmoplantar pustulosis.

Anybody can get palmoplantar pustulosis, but it is more common in women than in men and is rare in children. Those with family members who have palmoplantar pustulosis or psoriasis are more likely to be affected.

It is more common in people with other autoimmune conditions such as arthritis, diabetes, thyroid disorders, or coeliac disease.

Palmoplantar pustulosis can run in families, but most patients have no other affected family members.

The skin of the palms or soles can be very itchy and painful, mainly if there are deep cracks in the skin (fissures). The condition is persistent, but the symptoms can vary, becoming better and worse over time, often with no apparent cause. 

Often the inflammation of the skin of the palms and soles is symmetrical, but it can occur on just one side. In flare-ups, the skin is red, with tiny blisters filled with yellow/white liquid (pustules), and eventually, these turn brown and become scaly. 

In the more persistent stage, the skin can be dry and thickened and develop painful cracks (fissures). It can also affect one or more nails causing them to become thicker, discolor, develop ridges and pitting, and sometimes separate from the nail bed.

In most cases, the diagnosis is made by a doctor after taking a history and by looking at a person’s skin. As a fungal infection can look very similar, it can be helpful for a doctor to take a painless skin scrape to check for this. A painless swab of the fluid inside the pustules may be taken to rule out a bacterial infection. Sometimes, a small biopsy may be needed to confirm the diagnosis. This procedure requires a local anesthetic injection into an affected area and removing a small piece of skin to look at under the microscope. This is followed by stitches to close the wound, after which the area should heal with a small scar.

Although the condition is not cancerous or contagious, the inflammation of the palms and soles can severely affect one’s quality of life. It can be painful and itchy, making it hard for one to walk comfortably or to use their hands without pain, possibly affecting sleep, work, and activities of daily living.

No. Like many skin conditions, palmoplantar pustulosis cannot be cured. There are, however, several treatment options that can improve it significantly. Basic principles of good skincare can reduce the frequency and severity of symptoms (see below).

What is the treatment for palmoplantar pustulosis? Several different treatment options range from creams to phototherapy (UV light treatment in the Dermatology Department) to tablets, and it is individualized to the patient depending on the severity of their condition. It is not unusual for the treatment to change over time, as the disease is longstanding.

Creams and Ointments : 

• Moisturizers should be applied several times a day to prevent dryness and itching of the skin and act as barriers.
• Steroid creams and ointments reduce inflammation in the skin.
• Tar ointments.
• PUVA and re-PUVA are treatments with ultraviolet light A (UVA).
• Acitretin is a tablet related to Vitamin A and is one of a group of drugs called retinoids. This drug can be beneficial but is not usually recommended in women of childbearing age as pregnancy must be avoided during treatment and 3 years after taking it. A newer retinoid called alitretinoin has also been used with some success.
• Methotrexate and ciclosporin are also used and both work by reducing the immune response of the body Injections (Biologic therapies).
• These therapies work by altering the immune system. These are a relatively new treatment for palmoplantar pustulosis and currently only used for patients with very severe disease who cannot take one of the standard treatments listed above or who have failed to respond to them.
• Other treatments may also be tried, depending on individual circumstances and need. Medicines, as part of clinical research, may also be available. Your doctor will discuss treatment options with you.

• If you are a smoker, you should try to stop. The benefit to the skin from quitting smoking may not be immediately apparent, but your general health will also benefit. 
• Don’t use soap, bubble bath, or shower gel, instead use a moisturizing cream or ointment for washing the affected areas. A moisturizer should be applied several times a day to reduce inflammation and dryness. 
• Protective gloves should be worn when you work with water and exposure to chemicals, including household cleaning products. Appropriate gloves should also be worn for any gardening or manual labor. • If possible, rest your sore hands and feet.
• Wear socks and shoes made from cotton or very soft synthetic fibers, as they are better tolerated by inflamed skin. Cotton gloves and socks can also be used at night over ointments to reduce the transfer of cream to bed linen. Wool should be avoided as it can be irritant.
• Thickened skin will crack (fissure) more easily. The skin thickness can be reduced by applying the cream.
• A podiatrist can offer advice and treatment with foot care.