GRAND ROUNDS / PEER REVIEWED

Acute Palmar and Plantar Rash in a 52-Year-Old Woman

Clinician Reviews. 2019 October;29(10):12e-14e

References

1. Sevrain M, Richard M-A, Barnetche T, et al. Treatment for palmoplantar pustular psoriasis: systematic literature review, evidence-based recommendations and expert opinion. J Eur Acad Dermatol Venereol. 2014;28(suppl 5):13-16.
2. Olazagasti JM, Ma JE, Wetter DA. Clinical features, etiological factors, associated disorders, and treatment of palmoplantar pustulosis: the Mayo Clinic experience, 1996-2013. Mayo Clin Proc. 2017;92(9):1351-1358.
3. Bissonnette R, Suárez-Fariñas M, Li X, et al. Based on molecular profiling of gene expression, palmoplantar pustulosis and palmoplantar pustular psoriasis are highly related diseases that appear to be distinct from psoriasis vulgaris. PLoS One. 2016;11(5):1-11.
4. Raposo I, Torres T. Palmoplantar psoriasis and palmoplantar pustulosis: current treatment and future prospects. Am J Clin Dermatol. 2016;17(4):349-358.
5. Bissonnette R, Fuentes-Duculan J, Mashiko S, et al. Palmoplantar pustular psoriasis (PPPP) is characterized by activation of the IL-17A pathway. J Dermatol Sci. 2017;85(1):20-26.
6. Misiak-Galazka M, Wolska H, Rudnicka L. What do we know about palmoplantar pustulosis? J Eur Acad Dermatol Venereol. 2017;31(1):38-44.
7. Brunasso AMG, Puntoni M, Aberer W, et al. Clinical and epidemiological comparison of patients affected by palmoplantar plaque psoriasis and palmoplantar pustulosis: a case series study. Br J Dermatol. 2013;168(6):1243-1251.
8. Engin B, As¸kın Ö, Tüzün Y. Palmoplantar psoriasis. Clin Dermatol. 2017; 35(1):19-27.
9. Chung J, Callas Duffin K, Takeshita J, et al. Palmoplantar psoriasis is associated with greater impairment of health-related quality of life compared to moderate-to-severe plaque psoriasis. J Am Acad Dermatol. 2014;71(4):623-632.
10. Umezawa Y, Nakagawa H, Tamaki K. Phase III clinical study of maxacalcitol ointment in patients with palmoplantar pustulosis: a randomized, double-blind, placebo-controlled trial. J Dermatol. 2016;43(3):288-293.
11. Muro M, Kawakami H, Matsumoto Y, et al. Topical combination therapy with vitamin D₃ and corticosteroid ointment for palmoplantar pustulosis: a prospective, randomized, left-right comparison study. J Dermatolog Treat. 2016;27(1):51-53.
12. Gottlieb A, Sullivan J, van Doorn M, et al. Secukinumab shows significant efficacy in palmoplantar psoriasis: results from GESTURE, a randomized controlled trial. J Am Acad Dermatol. 2017;76(1):70-80.

Bacterial. A primary bacterial cause of bilateral skin lesions on the palms and the soles is uncommon. However, any open skin lesion can result in secondary bacterial infection. The pustules of PPP are often sterile and do not require bacterial culture; however, additional symptoms of fever, purulence, warmth, and worsening of symptoms may prompt further evaluation for a bacterial origin or complication.

Management

Due to limited quality data on treatment recommendations, the treatment options for PPP vary greatly. Most studies recommend topical versus systemic therapy for initial management.^1-2,8,10-11 Firstline therapy often consists of topical corticosteroids and occlusive dressings, followed by oral retinoids (acitretin, alitretinoin) or photochemotherapy.^1,8 Third-line therapy can include immunosuppressants (ciclosporin, methotrexate) or biologics (secukinumab).^1,12 Recent data have shown positive results with vitamin D₃ analogs (maxacalcitol, betamethasone butyrate propionate) as monotherapy or in combination with corticosteroids.^10-11 Duration of therapy ranges from 4 to 8 weeks throughout the literature, depending on severity; however, many patients see improvement in the first few weeks.

Conservative measures to maintain remission include smoking cessation, skin emollients, and avoidance of irritants. It is important to educate patients about the chronicity of the disease and early treatment to prevent secondary infection or significant impact on quality of life.

OUTCOME FOR THE CASE PATIENT

The patient was prescribed triamcinolone acetonide (0.5% ointment applied bid), to be used until symptoms improved. After 1 week of treatment, she confirmed (verbally) that symptoms had resolved. She declined a follow-up visit or referral to dermatology.

CONCLUSION

Although PPP is fairly uncommon, it is important for clinicians to consider this diagnosis in patients presenting with localized rash on their palms and soles. This debilitating condition greatly affects a patient’s quality of life and, although it is chronic in nature, available treatments described in the literature have shown success in both acute resolution and ongoing remission of the disease.

Acute Palmar and Plantar Rash in a 52-Year-Old Woman

References

Management

OUTCOME FOR THE CASE PATIENT

CONCLUSION

Pages

Recommended Reading