Updated: 2/15/2019

Pustulosis Palmoplantaris

Review Topic
  • Crops of sterile pustules that occur on one or both hands and feet, also known as pustular psoriasis
  • Introduction
    • 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)
  • 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
  • Prognosis
    • not contagious
    • varies in severity and can persist for many years
    • little effect on general health
  • 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
  • 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
  • Non-operative 
    • general measures
      • smoking cessation
      • skin moiturization
      • avoidance of irrtants
    • topical corticosteroids, oral retinoid, photochemotherapy
      • indications
        • first-line therapy
      • outcomes
        • low-risk for adverse effects with topical corticosteriod therapy



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