Palmoplantar pustulosis (PPP) is a chronic relapsing disorder associated with recurring crops of sterile pustules on palms and soles. Palmoplantar pustulation is frequently accompanied by the formation of erythematous desquamative plaques, which complicate the differentiation of PPP and palmoplantar psoriasis, a variant of plaque psoriasis. The diagnosis of PPP thus rests on histological studies. Considerable knowledge gaps regarding the etiology and pathogenesis of PPP hinder the development of effective therapies. Most patients receive immunosuppressive treatments or phototherapy, which may relieve their complaints, but long-term results are far from satisfying.
Dermatological findings characteristic of PPP comprise yellow pustules on palms and/or soles, that measure up to 10 mm in diameter, are well demarcated but tend to coalesce. These pustules erupt and resolve with brownish discoloration, and due to the relapsing course of PPP, brown macules developed during prior episodes are frequently observed adjacent to new pustules. During acute episodes, erythema may be noted on affected areas of palms and soles . Patients often claim burning sensations and itching . Hyperkeratosis and scaling may be seen. In the long term, painful cracks and fissures may form . While asymmetry is not an exclusion criterion, lesions often develop symmetrically .
As per definition, PPP-related skin lesions are limited to the palms and soles. Nevertheless, nail involvement is reported in about 10% of cases. Subungal pustulation may be associated with superficial anomalies like pitting and may eventually lead to onycholysis . Because PPP patients tend to present symptoms resulting from concomitant psoriasis, it may be difficult to clarify whether this finding is related to one disease or the other  . In the absence of extrapalmoplantar skin lesions, nail involvement is usually attributed to PPP . By contrast, erythematous desquamative plaques that extend beyond the limits of palms and soles are rather suggestive of plaque psoriasis, even in case of palmoplantar predominance, and plaque psoriasis is commonly associated with nail changes .
Entire Body System
Each pain score improved statistically significantly at the indicated times after the initiation of treatment (P < 0.05). The QoL score improved significantly with a good correlation with the relevant pain scores. [ncbi.nlm.nih.gov]
Palmoplanar pustules may rarely be associated with chronic recurrent multifocal osteomyelitis in children and young adults, Additional features of this disorder are recurrent low-grade fevers and bone pain. [scholars.northwestern.edu]
- Difficulty Walking
The most common complications include: difficulty walking or doing daily tasks pain that affects activities and sleep infection from scratching your itchy palms and soles It may not be possible to prevent all cases of palmoplantar pustulosis. [healthline.com]
Due to these symptoms, patients may have difficulty walking and performing other daily tasks with the hands and feet. < Previous section Next section > < Previous section Next section > Causes The exact cause of PPP is not known. [rarediseases.org]
- Burning Pain
At the same time the patient feels burning and pain in the inflammatory foci. New pustules appear undulatory and form suppurative spots. The emergence of new foci of inflammation is always accompanied by fever. [noskinproblems.com]
Brachytherapy has the advantage of providing a conformal dose distribution over complex curved surfaces, such as the foot and ankle. [ncbi.nlm.nih.gov]
This study demonstrated a coexistence of atopic dermatitis in over 50% of IA cases. The full text of this article is available in PDF format. [em-consulte.com]
On examination, she had multiple erythematous pustular lesions of 2–7 mm in diameter over the plantar surfaces of her feet ( figure 1 ). [casereports.bmj.com]
We observed significant reduction in the frequency of pustular eruptions and the number of pustules with maximum tolerable doses of colchicine treatment for up to 12 months. [ncbi.nlm.nih.gov]
Despite the paucity of reported cases of infantile acropustulosis, the collected experience has suggested that black males have a predisposition for this eruption, although affected infants of both sexes and all races have been identified. [pedsinreview.aappublications.org]
[acro + pustulosis] infantile a. a cyclically recurrent vesicopustular and crusting pruritic eruption, usually in black children, appearing soon after birth to … Medical dictionary infantile acropustulosis — a congenital condition characterized by small [translate.academic.ru]
Palmoplantar pustulosis (PPP) is characterized by neutrophilic pustules with erythema, which are limited to the hands and feet. [ncbi.nlm.nih.gov]
Acropustulosis, or chronic palmar plantar pustulosis (PPP), is a phenomenon of recurrent sterile pustules, erythema, and scaling affecting the palms and soles. Its pathogenesis is unclear, and it is difficult to treat. [mayoclinic.pure.elsevier.com]
Your doctor will examine the skin on your palms and soles to check for blisters or pustules. They may need to do several tests to rule out other medical problems. [healthline.com]
ANSWER Acropustulosis is a rare form of pustular psoriasis that causes pus-filled blisters to form on the tips of your fingers and toes, often beneath the nails. [webmd.com]
Typically, an infant develops small flat red areas on the palms and soles which become raised, develop into tiny blisters, then pustules, which heal with small temporary pigmented areas. The lesions are itchy. [dermnetnz.org]
Palmoplantar pustulosis (PPP) is a chronic pustular dermatitis of the palms and soles, which is frequently associated with significant pruritus and pain, often limiting daily activities. [ncbi.nlm.nih.gov]
Topical pramoxine preparations are available without prescription for the treatment of pruritus. Oral antihistamines may be useful in infantile acropustulosis to help decrease pruritus. [emedicine.medscape.com]
Family members should also be questioned and examined for pruritus and burrows. Eosinophilic folliculitis occurs mainly on the scalp rather than the hands and feet but may cycle concurrently with AI. [visualdx.com]
This point may need to be emphasised to the family: aside from the pruritus being unpleasant, this condition has no particular consequences. × N.B. : This limited content is for the general public. [therapeutique-dermatologique.org]
We present an 8-month-old black boy with very pruritic papules on his wrists and ankles, treated repeatedly with antiscabietic agents. A punch biopsy was done and revealed findings consistent with acropustulosis. [ejpd.com]
This rash typically presents with erythematous papules to the hands and feet. The lesions can also be present on the buttocks, arms, and legs. [elitecme.com]
It is characterized by recurrent crops of pruriginous vesicles, papules and pustules affecting the acral areas. It is self-resolving. Its etiology is unknown but it can be associated with scabies. [ijord.com]
The onset consists of small macules and papules which progress to form vesicles and then pustules of 1 - 3 mm in diameter. [therapeutique-dermatologique.org]
Early lesions are discrete, 1- to 2-mm erythematous papules, which became vesiculopustular within 24 hours (Fig 1, top left) and subsequently crust prior to healing. [pedsinreview.aappublications.org]
In the presence of psoriatic skin lesions outside the palmoplantar region, the differentiation of PPP and psoriasis may pose a major challenge. Indeed, it may not be possible to clinically distinguish PPP from palmoplantar psoriasis in these cases . Otherwise, PPP is diagnosed clinically.
In case of doubts, histological studies may be carried out to support the tentative diagnosis of PPP. Tissue samples are obtained by skin biopsy, and their microscopic examination reveals the neutrophilic infiltration of the acrosyringium of sweat glands . The spiral architecture of these eccrine ducts may be lost . Acanthosis and parakeratosis may be observed but don't usually dominate the image. PPP-related pustules are sterile lesions, which is reflected in histological and microbiological findings .
Because the etiology and pathogenesis of PPP remain poorly understood, causal treatment is not available. In the majority of cases, corticosteroids are applied on affected areas. The thicker stratum corneum of palms and soles diminishes the efficacy of topically delivered agents, so they are generally applied under hydrocolloid dressing occlusion. Corticosteroids may be combined with retinoids to potentiate the efficacy of the former and to minimize the risk of side effects . If topical medication doesn't yield the desired effect, immunosuppressive and/or anti-inflammatory drugs may be administered systemically. Acitretin and methotrexate are most commonly prescribed to this end . Regardless of the decision for topical or systemic medication, continued treatment is often required after achieving remission to avoid the recurrence of pustulation . Phototherapy constitutes a valuable alternative to the immunosuppressive approach. Oral psoralen plus irradiation with ultraviolet light A alleviates symptoms in the majority of patients, but recurrence is equally likely upon the cessation of therapy  .
Either of the aforementioned therapeutic approaches has been reported to induce complete or partial responses but has proven ineffective in other instances, which highlights the need for new PPP treatments  . Current research is focused on countering disturbances of the immune system, e.g., by antagonizing IL-17. Secukinumab and ixekizumab are monoclonal antibodies against IL-17 whose safety and efficacy in PPP management have been tested in clinical trials. The results of these trials are highly promising . At the same time, other targets of PPP immunotherapy are studied: Inhibitors of phosphodiesterase-4 gained the attention of scientists, and apremilast has successfully been used to treat PPP . Apremilast has been shown to inhibit numerous T-cell-derived cytokines, including but not limited to IL-17, interferon-γ, and tumor necrosis factor-α  . Although tumor necrosis factor antagonists have been implicated in the pathogenesis of the disease , infliximab, a monoclonal antibody against tumor necrosis factor-α, has proven effective in PPP therapy .
PPP is a painful and sometimes disabling condition with a significant impact on the patient's quality of life. During severe episodes, PPP patients may not be able to use their hands or walk . The disease has a chronic course with intermittent flares mostly followed by partial, rarely by complete remissions . The mean duration of PPP is 7 years, but some patients suffer for decades . Current knowledge regarding the causes and course of the disease does not allow for a prediction of disease duration in individual cases.
The triggers of PPP remain unknown. Smoking, an increased physical, emotional, or psychological burden due to infectious diseases, stress, and anxiety, as well as immunomodulators like tumor necrosis factor antagonists, have been linked to the development of PPP and the aggravation of episodes  . Furthermore, PPP has been associated with systemic disorders like diabetes mellitus type 2, autoimmune thyroid disease, celiac disease, and SAPHO syndrome  . These observations may suggest an immunological component in PPP pathogenesis. Indeed, molecular biological studies revealed an overexpression of IL-17 in palms and soles of PPP patients .
PPP has also been related to missense mutations in the CARD14 gene, which encodes for caspase recruitment domain family member 14, a protein that is involved in cellular adhesion and proinflammatory signaling . By contrast, European and Asian studies argue against an involvement of the IL36RN gene in the pathogenesis of PPP  . Both mutations of CARD14 and IL36RN have been detected in patients suffering from plaque psoriasis, so there is an overlap of genetic susceptibility, but there are differences, too. These differences may account for the characteristic distribution of pustular lesions in PPP patients, and they may possibly explain treatment success and failure.
PPP is a chronic disorder that may affect patients of any age, gender, and ethnicity. The disease is diagnosed at a mean age of 45 years, but it has also been reported in children and adults of very old age . The majority of affected individuals is female  . In Japan, the prevalence of PPP has been estimated to 0.12% .
PPP-related vesicles form in the upper coiled ducts of eccrine sweat glands, i.e., in the acrosyringium . Histologically, these vesicles impress by the infiltration of neutrophils, which are surrounded by lymphocytes that have been shown to produce IL-6, IL-17, interferon-γ, and tumor necrosis factor-α. Distinct hypotheses have been postulated to explain this condition :
On the one hand, smoking is associated with nicotine excretion via the sweat glands, and nicotine may alter the reaction of immune cells in the acrosyringium. Smoking has also been related to the generation of autoantibodies against nicotinic acetylcholine receptors. Such antibodies have been found to bind to epitopes in the palmar sweat glands .
On the other hand, the aforementioned lymphocytes may derive from memory effector cells that have been generated in the context of tonsillitis or upper respiratory infections. But even though evidence has been provided that such effector cells may home to the skin , the question of the disease' limitation to the palmoplantar region remains unanswered. Regardless of the latter, the hypothesis is supported by a Japanese metastudy describing the exacerbation of PPP upon acute tonsillitis, and marked improvement or complete remission of PP after tonsillectomy . These processes may be favored by a genetic predisposition of the PPP patient.
Few recommendations can be given to prevent PPP or to avoid episodes of renewed pustulation. Certain lifestyle decisions may be helpful to lower the individual risk of developing PPP, such as the decision to refrain from smoking. However, it remains unclear whether the cessation of smoking after the onset of symptoms affects the course of the disease . In general, PPP patients may benefit from measures to prevent infectious diseases and to reduce their overall burden of stress, but evidence has not yet been provided to this end. In the few cases where PPP can clearly be attributed to the administration of determined drugs, namely inhibitors of tumor necrosis factor-α, the feasibility of switching to an alternative agent should be ascertained .
PPP is a chronic skin disease that is limited to the palms and soles. For a long time, it has been considered a localized pustular variant of psoriasis. This changed in 2007, when PPP was re-classified as a separate entity . Nevertheless, the classification of PPP remains an issue of ongoing debate. The high incidence of psoriasis among PPP patients - about one-third of those suffering from PPP present psoriasis-related symptoms - suggests an etiological association between these two conditions  .
In general, the etiology remains poorly understood. A variety of genetic and environmental factors has been discussed in this context, but the specific triggers of symptom onset and flare-ups have not yet been identified. Accordingly, it is not yet possible to predict acute episodes, exacerbations, and the long-term course of the disease.
Most patients receive topical or systemic immunosuppressive treatment or phototherapy, but symptoms often recur after the discontinuation of therapy  . Prolonged treatments, however, are associated with considerable side effects, so an acceptable compromise between the latter and PPP-related disability has to be sought . Spontaneous remission may occur after prolonged periods of time, possibly after decades, but has also been reported after a brief period of severe illness.
Palmoplantar pustulosis (PPP) is a chronic skin disease of as-of-yet unknown cause. PPP patients suffer from episodic pustulations involving their palms and/or soles. Numerous yellow pustules form in affected areas, erupt and resolve with brownish decoloration. Flare-ups may be associated with burning and itching, and are generally painful. They may hinder the patients to use their hands or to walk. In the long term, affected individuals may note an exuberant cornification and scaling, and fissures and cracks may appear. A minor portion of patients presents with nail changes, but PPP-related pustules don't usually form outside the palmoplantar region. This is important to note because the distribution of skin lesions allows for the differentiation of PPP and plaque psoriasis. Nevertheless, doubts may remain regarding the distinction of PPP from an equally limited variant of plaque psoriasis. If a clinical diagnosis is deemed unfeasible, the dermatologist may opt for a skin biopsy. This way, tissue samples can be obtained for histological studies.
There are different ways to treat PPP. Unfortunately, though, causal therapies are not available, and the cure of PPP cannot be achieved in all cases. The most common approach to PPP treatment involves the topical application of corticosteroids. If it doesn't yield the desired results, immunosuppressive and anti-inflammatory agents may be administered systemically. Phototherapy constitutes an alternative to immunosuppression. While all these therapies may alleviate symptoms, recurrence is likely after the cessation of treatment. Its continuation may, however, have considerable side effects. An acceptable compromise needs to be found that considers the response of the individual patient.
Complete remission has been achieved by drug therapy or spontaneously, but it is not currently possible to predict exacerbations and remissions or the long-term outcome of the disease.
- Olazagasti JM, Ma JE, Wetter DA. Clinical Features, Etiologic Factors, Associated Disorders, and Treatment of Palmoplantar Pustulosis: The Mayo Clinic Experience, 1996-2013. Mayo Clin Proc. 2017; 92(9):1351-1358.
- Marsland AM, Chalmers RJ, Hollis S, Leonardi-Bee J, Griffiths CE. Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev. 2006; (1):Cd001433.
- Hiraiwa T, Yamamoto T. Nail involvement associated with palmoplantar pustulosis. Int J Dermatol. 2017; 56(2):e28-e29.
- Brunasso AMG, Massone C. Psoriasis and palmoplantar pustulosis: an endless debate? J Eur Acad Dermatol Venereol. 2017; 31(7):e335-e337.
- Raposo I, Torres T. Palmoplantar Psoriasis and Palmoplantar Pustulosis: Current Treatment and Future Prospects. Am J Clin Dermatol. 2016; 17(4):349-358.
- Naik HB, Cowen EW. Autoinflammatory pustular neutrophilic diseases. Dermatol Clin. 2013; 31(3):405-425.
- Adişen E, Gürer MA. Therapeutic options for palmoplantar pustulosis. Clin Exp Dermatol. 2010; 35(3):219-222.
- Wilsmann-Theis D, Jacobi A, Frambach Y, et al. Palmoplantar pustulosis - a cross-sectional analysis in Germany. Dermatol Online J. 2017; 23(4).
- Haebich G, Kalavala M. Successful treatment of refractory palmoplantar pustulosis with apremilast. Clin Exp Dermatol. 2017.
- Schafer PH, Parton A, Capone L, et al. Apremilast is a selective PDE4 inhibitor with regulatory effects on innate immunity. Cell Signal. 2014; 26(9):2016-2029.
- Shmidt E, Wetter DA, Ferguson SB, Pittelkow MR. Psoriasis and palmoplantar pustulosis associated with tumor necrosis factor-alpha inhibitors: the Mayo Clinic experience, 1998 to 2010. J Am Acad Dermatol. 2012; 67(5):e179-185.
- Sanchez IM, Sorenson E, Levin E, Liao W. The Efficacy of Biologic Therapy for the Management of Palmoplantar Psoriasis and Palmoplantar Pustulosis: A Systematic Review. Dermatol Ther (Heidelb). 2017; 7(4):425-446.
- Bissonnette R, Nigen S, Langley RG, et al. Increased expression of IL-17A and limited involvement of IL-23 in patients with palmo-plantar (PP) pustular psoriasis or PP pustulosis; results from a randomised controlled trial. J Eur Acad Dermatol Venereol. 2014; 28(10):1298-1305.
- Mössner R, Frambach Y, Wilsmann-Theis D, et al. Palmoplantar Pustular Psoriasis Is Associated with Missense Variants in CARD14, but Not with Loss-of-Function Mutations in IL36RN in European Patients. J Invest Dermatol. 2015; 135(10):2538-2541.
- Takahashi T, Fujimoto N, Kabuto M, Nakanishi T, Tanaka T. Mutation analysis of IL36RN gene in Japanese patients with palmoplantar pustulosis. J Dermatol. 2017; 44(1):80-83.
- Kubota K, Kamijima Y, Sato T, et al. Epidemiology of psoriasis and palmoplantar pustulosis: a nationwide study using the Japanese national claims database. BMJ Open. 2015; 5(1):e006450.
- Hagforsen E, Awder M, Lefvert AK, Nordlind K, Michaëlsson G. Palmoplantar pustulosis: an autoimmune disease precipitated by smoking? Acta Derm Venereol. 2002; 82(5):341-346.
- Nozawa H, Kishibe K, Takahara M, Harabuchi Y. Expression of cutaneous lymphocyte-associated antigen (CLA) in tonsillar T-cells and its induction by in vitro stimulation with alpha-streptococci in patients with pustulosis palmaris et plantaris (PPP). Clin Immunol. 2005; 116(1):42-53.
- Wu W, Debbaneh M, Moslehi H, Koo J, Liao W. Tonsillectomy as a treatment for psoriasis: a review. J Dermatolog Treat. 2014; 25(6):482-486.