summary Pustulosis Palmoplantaris, also known as pustular psoriasis, is an idiopathic skin condition commonly seen in smokers, that presents with crops of sterile pustules that occur on one or both hands and feet. Diagnosis is one of exclusion and is made with the presence of 1 to 10 mm sterile pustules on palms or feet with surrounding erythema and fissures. No serological tests are specific for disease. Treatment is usually general measures such as smoking cessation, avoiding skin irritants, and medical management with topical corticosteroids. Epidemiology Demographics more common in middle-aged men than in women rare in children Risk factors the majority of patients are smokers (65–90%) increased stress infection (i.e acute or chronic tonsillitis) drugs (i.e.TNF-alpha inhibitors) Etiology Pathophysiology unknown therories activated nicotine receptors in the sweat glands cause an inflammatory process Associated conditions orthopaedic conditions chronic recurrent multifocal osteomyelitis synovitis–acne–pustulosis–hyperostosis–osteomyelitis (SAPHO) syndrome rare presentations of arthropathy medical conditions & comorbidities autoimmune diseases gluten sensitive enteropathy (celiac disease) thyroid disease type 1 diabetes Presentation Symptoms pruritis, bruning sensation and occasionally pain worsend by pressure, rubbing and friction may have discomfort walking significant psychologic effect Physical exam inspection 1 to 10 mm sterile pustules on palms +/- soles of feet surrounding erythema and fissures usually bilateral motion joint pain suggestive of SAPHO Studies Labs no serological tests are specific for disease laboratory tests for bacterial infection are negative Biopsy and diagnositc injections skin biopsy may be helpful but is rarely necessary Treatment Non-operative general measures smoking cessation skin moiturization avoidance of irritants topical corticosteroids, oral retinoid, photochemotherapy indications first-line therapy outcome slow-risk for adverse effects with topical corticosteriod therapy Prognosis Not contagious Varies in severity and can persist for many years Little effect on general health