Palmoplantar pustulosis: Treatment
- Giovanna Brunasso, MD
Giovanna Brunasso, MD
- First Level Medical Director
- Department of Dermatology
- Galliera Hospital
- Cesare Massone, MD
Cesare Massone, MD
- Medical Director, Dermatology Unit
- Galliera Hospital, Genova, Italy
- Associate Professor, Department of Dermatology
- Medical University of Graz, Graz, Austria
Palmoplantar pustulosis (PPP) is an uncommon chronic skin disorder characterized by recurrent eruptions of pustules on the palms and soles (picture 1A-F). Scale, erythema, pruritus, burning sensations, and pain are common associated features.
Although PPP involves a limited area, the disorder can have a significant negative effect on quality of life and can interfere with performance of activities of daily living. Patients with PPP on the soles of the feet may experience difficulty walking, and hand involvement may interfere with other activities.
PPP tends to have a prolonged course consisting of periods of exacerbation and partial remission. The treatment of the disease is often challenging, as responses to individual treatments are variable and unpredictable.
The management of PPP will be reviewed here. The clinical manifestations and diagnosis of PPP are reviewed separately. (See "Palmoplantar pustulosis: Epidemiology, clinical features, and diagnosis".)
High quality data on the treatment of palmoplantar pustulosis (PPP) are limited, contributing to uncertainty about the ideal approach to treatment. Although multiple randomized trials have been performed, most are small and of poor methodological quality . Moreover, the lack of a standardized method for assessing the response to treatment, as well as the wide variability in treatment regimens, complicate comparisons of study findings.
- Marsland AM, Chalmers RJ, Hollis S, et al. Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev 2006; :CD001433.
- Brunasso AM, 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; 168:1243.
- Michaëlsson G, Gustafsson K, Hagforsen E. The psoriasis variant palmoplantar pustulosis can be improved after cessation of smoking. J Am Acad Dermatol 2006; 54:737.
- Adişen E, Tekin O, Gülekon A, Gürer MA. A retrospective analysis of treatment responses of palmoplantar psoriasis in 114 patients. J Eur Acad Dermatol Venereol 2009; 23:814.
- Kragballe K, Larsen FG. A hydrocolloid occlusive dressing plus triamcinolone acetonide cream is superior to clobetasol cream in palmo-plantar pustulosis. Acta Derm Venereol 1991; 71:540.
- Lassus A, Geiger JM. Acitretin and etretinate in the treatment of palmoplantar pustulosis: a double-blind comparative trial. Br J Dermatol 1988; 119:755.
- Lassus A, Lauharanta J, Juvakoski T, Kanerva L. Efficacy of etretinate (Tigason) in clearing and prevention of relapse of palmoplantar pustulosis. Dermatologica 1983; 166:215.
- Aldrich MS, Foster NL, White RF, et al. Sleep abnormalities in progressive supranuclear palsy. Ann Neurol 1989; 25:577.
- Murray D, Corbett MF, Warin AP. A controlled trial of photochemotherapy for persistent palmoplantar pustulosis. Br J Dermatol 1980; 102:659.
- Rosén K, Mobacken H, Swanbeck G. PUVA, etretinate, and PUVA-etretinate therapy for pustulosis palmoplantaris. A placebo-controlled comparative trial. Arch Dermatol 1987; 123:885.
- Lassus A, Lauharanta J, Eskelinen A. The effect of etretinate compared with different regimens of PUVA in the treatment of persistent palmoplantar pustulosis. Br J Dermatol 1985; 112:455.
- Matsunami E, Takashima A, Mizuno N, et al. Topical PUVA, etretinate, and combined PUVA and etretinate for palmoplantar pustulosis: comparison of therapeutic efficacy and the influences of tonsillar and dental focal infections. J Dermatol 1990; 17:92.
- Layton AM, Sheehan-Dare R, Cunliffe WJ. A double-blind, placebo-controlled trial of topical PUVA in persistent palmoplantar pustulosis. Br J Dermatol 1991; 124:581.
- Lawrence CM, Marks J, Parker S, Shuster S. A comparison of PUVA-etretinate and PUVA-placebo for palmoplantar pustular psoriasis. Br J Dermatol 1984; 110:221.
- Reitamo S, Erkko P, Remitz A, et al. Cyclosporine in the treatment of palmoplantar pustulosis. A randomized, double-blind, placebo-controlled study. Arch Dermatol 1993; 129:1273.
- Erkko P, Granlund H, Remitz A, et al. Double-blind placebo-controlled study of long-term low-dose cyclosporin in the treatment of palmoplantar pustulosis. Br J Dermatol 1998; 139:997.
- Thomsen K. Pustulosis palmaris et plantaris treated with methotrexate. Acta Derm Venereol 1971; 51:397.
- Brunasso AM, Laimer M, Massone C. Paradoxical reactions to targeted biological treatments: A way to treat and trigger? Acta Derm Venereol 2010; 90:183.
- Shmidt E, Wetter DA, Ferguson SB, Pittelkow MR. Psoriasis and palmoplantar pustulosis associated with tumor necrosis factor-α inhibitors: the Mayo Clinic experience, 1998 to 2010. J Am Acad Dermatol 2012; 67:e179.
- Bissonnette R, Poulin Y, Bolduc C, et al. Etanercept in the treatment of palmoplantar pustulosis. J Drugs Dermatol 2008; 7:940.
- Hampton SL, Youssef H. Successful treatment of resistant SAPHO syndrome with anti-TNF therapy. BMJ Case Rep 2013; 2013.
- De Souza A, Solomon GE, Strober BE. SAPHO syndrome associated with hidradenitis suppurativa successfully treated with infliximab and methotrexate. Bull NYU Hosp Jt Dis 2011; 69:185.
- Arias-Santiago S, Sanchez-Cano D, Callejas-Rubio JL, et al. Adalimumab treatment for SAPHO syndrome. Acta Derm Venereol 2010; 90:301.
- Ben Abdelghani K, Dran DG, Gottenberg JE, et al. Tumor necrosis factor-alpha blockers in SAPHO syndrome. J Rheumatol 2010; 37:1699.
- Fruehauf J, Cierny-Modrè B, Caelen Lel-S, et al. Response to infliximab in SAPHO syndrome. BMJ Case Rep 2009; 2009.
- Sabugo F, Liberman C, Niedmann JP, et al. Infliximab can induce a prolonged clinical remission and a decrease in thyroid hormonal requirements in a patient with SAPHO syndrome and hypothyroidism. Clin Rheumatol 2008; 27:533.
- 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; 28:1298.
- Gerdes S, Franke J, Domm S, Mrowietz U. Ustekinumab in the treatment of palmoplantar pustulosis. Br J Dermatol 2010; 163:1116.
- Bertelsen T, Kragballe K, Johansen C, Iversen L. Efficacy of ustekinumab in palmoplantar pustulosis and palmoplantar pustular psoriasis. Int J Dermatol 2014; 53:e464.
- Morales-Múnera C, Vilarrasa E, Puig L. Efficacy of ustekinumab in refractory palmoplantar pustular psoriasis. Br J Dermatol 2013; 168:820.
- Chu DH, Van Voorhees AS, Rosenbach M. Treatment of refractory tumor necrosis factor inhibitor-induced palmoplantar pustulosis: a report of 2 cases. Arch Dermatol 2011; 147:1228.
- Puig L, Morales-Múnera CE, López-Ferrer A, Geli C. Ustekinumab treatment of TNF antagonist-induced paradoxical psoriasis flare in a patient with psoriatic arthritis: case report and review. Dermatology 2012; 225:14.
- Thomsen K, Osterbye P. Pustulosis palmaris et plantaris. Br J Dermatol 1973; 89:293.
- Ward JM, Corbett MF, Hanna MJ. A double-blind trial of clomocycline in the treatment of persistent palmoplantar pustulosis. Br J Dermatol 1976; 95:317.
- Thestrup-Pedersen K, Reymann F. Treatment of pustulosis palmaris et plantaris with colchicine. A double-blind cross-over trial. Acta Derm Venereol 1984; 64:76.
- Mann RJ. Failure of colchicine for palmo-plantar pustulosis. Br J Dermatol 1982; 106:373.
- V'lckova-Laskoska MT, Caca-Biljanovska NG, Laskoski DS, Kamberova SJ. Palmoplantar pustulosis treated with itraconazole: a single, active-arm pilot study. Dermatol Ther 2009; 22:85.
- Mihara M, Hagari Y, Morimura T, et al. Itraconazole as a new treatment for pustulosis palmaris et plantaris. Arch Dermatol 1998; 134:639.
- Takahara M. Clinical outcome of tonsillectomy for palmoplantar pustulosis and etiological relationship between palmoplantar pustulosis and tonsils. Adv Otorhinolaryngol 2011; 72:86.
- Kikuchi N, Yamamoto T. Dental infection as a triggering factor in palmoplantar pustulosis. Acta Derm Venereol 2013; 93:721.
- Akiyama T, Seishima M, Watanabe H, et al. The relationships of onset and exacerbation of pustulosis palmaris et plantaris to smoking and focal infections. J Dermatol 1995; 22:930.
- Ono T. Evaluation of tonsillectomy as a treatment for pustulosis palmaris et plantaris. J Dermatol 1977; 4:163.
- Ono T, Jono M, Kito M, et al. Evaluation of tonsillectomy as a treatment for pustulosis palmaris et plantaris. Acta Otolaryngol Suppl 1983; 401:12.
- Noda Y, Ura M. Pustulosis palmaris et plantaris due to tonsillar focal infections. From the analysis of long-term observed cases. Acta Otolaryngol Suppl 1983; 401:22.
- Michaëlsson G, Kristjánsson G, Pihl Lundin I, Hagforsen E. Palmoplantar pustulosis and gluten sensitivity: a study of serum antibodies against gliadin and tissue transglutaminase, the duodenal mucosa and effects of gluten-free diet. Br J Dermatol 2007; 156:659.
- Fumimori T, Tsuruta D, Kawakami T, et al. Effect of monochromatic excimer light on palmoplantar pustulosis: a clinical study performed in a private clinic by a dermatological specialist. J Dermatol 2013; 40:1004.
- Aubin F, Vigan M, Puzenat E, et al. Evaluation of a novel 308-nm monochromatic excimer light delivery system in dermatology: a pilot study in different chronic localized dermatoses. Br J Dermatol 2005; 152:99.
- Kawada A, Matsuda H, Oiso N. Efficacy and safety of targeted narrowband ultraviolet B therapy using a flat-type fluorescent lamp for the treatment of palmoplantar pustulosis. J Dermatol 2013; 40:754.
- Kim JY, Kang HY, Lee ES, Kim YC. Topical 5-aminolaevulinic acid photodynamic therapy for intractable palmoplantar psoriasis. J Dermatol 2007; 34:37.
- Lindelöf B, Beitner H. The effect of grenz ray therapy on pustulosis palmoplantaris. A double-blind bilateral trial. Acta Derm Venereol 1990; 70:529.
- Koga T, Sato T, Umeda M, et al. Successful treatment of palmoplantar pustulosis with rheumatoid arthritis, with tofacitinib: Impact of this JAK inhibitor on T-cell differentiation. Clin Immunol 2016; 173:147.
- Timerman D, Devlin PM, Nambudiri VE, et al. Novel application of high-dose rate brachytherapy for severe, recalcitrant palmoplantar pustulosis. Clin Exp Dermatol 2016; 41:498.