Although there is no cure for palmoplantar pustulosis, treatment can help manage symptoms. Because palmoplantar pustulosis can be resistant to treatment, however, it may take some time to find what works for you. Certain preventative measures can bring the condition under control before it starts.
Early diagnosis, trigger identification, and appropriate treatment are crucial. After an aggravating factor is removed, pustules gradually stop forming over 6 months or 1-2 years.
How is palmoplantar pustulosis treated?
Treatment options for palmoplantar pustulosis include:
- Topical steroids
- Moisturizing creams
- Tar ointments
- Oral retinoids
- Phototherapy, ultraviolet light therapy, or psoralen plus ultraviolet-A (PUVA)
- Potent to super potent topical corticosteroids are applied twice daily with or without occlusion, with frequency gradually decreasing over weeks to months.
- Calcipotriene is frequently combined with or alternated with highly active topical corticosteroids. However, calcipotriene should not be combined with salicylic acid because the resulting molecule is deactivated.
- Acitretin is a first-line systemic treatment that has a maximum effect 3-6 months after treatment begins.
- Light therapy, such as PUVA and narrowband ultraviolet-B (ND-UVB) phototherapy or monochromatic excimer laser, is preferred. Methotrexate and cyclosporine are other second-line systemic agents.
- Reports suggest that laser and other excimer light therapies may be effective. These novel treatments require a low cumulative dose to alleviate symptoms, resulting in fewer treatments.
- Biologics are only used in patients who have failed or are unable to complete treatment with topical or other systemic medications.
Though there is no standardized treatment for patients with palmoplantar psoriasis or pustulosis, more data on treatments, particularly biologic agents, have been released in recent years.
Studies suggest that patients may benefit from topical and systemic treatments. Overall, it appears that oral retinoids, with or without photochemotherapy, combined with low-dose corticosteroids or cyclosporine, work best for symptom relief. The initial regimen appears to be systemic retinoids and oral PUVA.
Many patients with psoriasis have other comorbidities, such as renal failure, liver disease, cancer, or heart failure, which predisposes them to medication side effects. Therefore, before beginning treatment, each patient must undergo a careful risk versus benefit analysis.
What are the symptoms of palmoplantar pustulosis?
Palmoplantar pustulosis is a chronic skin condition that affects the palms of the hands and soles of the feet. Common signs and symptoms include:
- Pus-filled blisters on the palms of the hands and soles of the feet (sterile pustules)
- Pustules usually appear in clusters, dry up around the same time, and then reappear
- Red, itchy, and painful patches
- Thickened skin
- Flaking and scaling skin
- Lesions and painful cracks over the skin
Symptoms can appear suddenly or worsen gradually over time. Nail involvement has been reported in approximately 10% of cases.
What are complications of palmoplantar pustulosis?
Possible complications of palmoplantar pustulosis include:
- Emotional stress caused by aesthetic concerns
- Difficulty carrying out simple tasks
- Relapse and remission
- Skin diseases caused by bacteria and fungi
- Difficulties and problems in treatment
What are risk factors for palmoplantar pustulosis?
Currently, the exact cause of palmoplantar pustulosis is unknown, but possible and risk factors include:
- Autoimmune inflammatory conditions
- Abnormalities in the sweat gland function on the palms and soles
- Family history of the condition (involvement of the IL36RN gene is noted in a few cases)
- Drugs (tumor necrosis factor [TNF)] alpha inhibitors have been implicated in some cases)
- Smoking (because most people with palmoplantar pustulosis have a history of smoking, it is thought that nicotine in cigarettes may play a role in the development of this condition)
- History of psoriasis
- Contact allergies
- History of chronic infections or current infection (strep throat)
- Injury to the affected area
- Environmental and weather changes
Having a risk factor does not guarantee that you will develop the condition; it merely increases your likelihood of developing a condition as compared to someone with no risk factors. Furthermore, the absence of risk factors does not rule out the possibility of developing the condition.
How is palmoplantar pustulosis managed?
While it may not be possible to prevent palmoplantar pustulosis, risk factors for the condition can be mitigated:
- Identify and avoid triggers
- Maintain a healthy lifestyle
- Moisturize your skin
- Use moisturizing lotions or creams at least twice a day to keep your skin hydrated
- Choose moisturizers with natural and organic ingredients
- Avoid irritants
- Do not use harsh soaps and detergents that can dry out your skin
- Use liquid cleansers or milder bar soap that are specifically designed for sensitive skin
- Wear protective clothing
- Wear gloves or socks when in cold weather or using sharp tools
- Shield your skin from heat and friction, which can aggravate the condition
- Wear nonirritating fabrics and avoid going barefoot
- Take vitamin D supplements
- Vitamin D supplements may strengthen your immune system and reduce symptoms
- Use topical remedies
- Using topical remedies prescribed by a doctor may help alleviate redness and irritation within a few days
- Do not continue using topical treatments for more than 2 weeks because it can cause negative effects
Your dermatologist can help you determine what treatments for palmoplantar pustulosis are best for you depending on the severity of your symptoms and how they respond to different remedies.
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National Organization for Rare Disorders. Palmoplantar Pustulosis. https://rarediseases.org/rare-diseases/palmoplantar-pustulosis
WebMD. Palmoplantar Pustulosis on Hands and Feet. https://www.webmd.com/skin-problems-and-treatments/psoriasis/palmoplantar-pustulosis
Freitas E, Rodrigues MA, Torres T. Diagnosis, Screening and Treatment of Patients with Palmoplantar Pustulosis (PPP): A Review of Current Practices and Recommendations. Clin Cosmet Investig Dermatol. 2020;13:561-578. doi:10.2147/CCID.S240607/
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