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Palmoplantar Pustular Psoriasis

Chronic recurrent localized variant of pustular psoriasis affecting palms and soles with sterile pustules on erythematous, scaly skin causing significant functional impairment, often refractory to topical therapy and frequently requiring systemic treatment.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Dermatoloji department. Book Appointment →

What is Palmoplantar Pustular Psoriasis?

Palmoplantar pustular psoriasis (PPP) is a chronic, recurrent, localized variant of pustular psoriasis characterized by sterile yellowish 2-4 mm pustules on erythematous, scaly, hyperkeratotic skin of palms and soles.

Pathophysiology involves IL-36 cytokine signaling, TNF-α, and IL-17 dysregulation in genetically susceptible individuals (IL36RN, AP1S3 mutations in some cases). Strong association with smoking (in 95% of patients) and HLA-B27 in some cohorts.

Considered distinct from generalized pustular psoriasis with different genetics and pathogenesis. Often misclassified historically, now recognized as a separate entity in IPC classification. Female predominance (3-4:1), peak onset 40-60 years, frequently associated with thyroid disease and metabolic syndrome.

Symptoms

Sterile yellowish 2-4 mm pustules on palms and soles
Pustules evolve to brown-yellow crusted lesions
Erythematous hyperkeratotic skin between pustules
Painful fissures and cracks affecting daily function
Difficulty walking, gripping, and using hands
Recurrent waves of pustulation every 2-4 weeks
Nail involvement: pitting, oil drop sign, onycholysis
Postinflammatory pigment changes after resolution

Risk Factors

Smoking (95% of PPP patients are current/former smokers)
Female sex (3-4:1 female predominance)
Age 40-60 years at onset
Family history of psoriasis (less than plaque psoriasis)
HLA-B27, HLA-Cw6 in subset of patients
Thyroid disease (autoimmune thyroiditis)
Metabolic syndrome and obesity
Stress as a trigger for flares

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Recurrent pustules on palms or soles
  • Persistent painful fissures affecting walking or hand function
  • Failed topical therapy after 4-6 weeks
  • Significant functional impairment from severe disease
  • Diagnostic uncertainty (differential: dyshidrotic eczema, tinea, scabies)
  • Family history of psoriasis with new palmoplantar lesions
  • Coexisting plaque psoriasis flare

Treatment Methods

01
Smoking cessation strongly recommended (most important modifiable factor)
02
Topical: super-potent corticosteroids under occlusion (clobetasol 0.05% twice daily)
03
Topical retinoids (tazarotene 0.05-0.1% gel) and vitamin D analogs combination
04
Topical calcineurin inhibitors: tacrolimus 0.1% ointment (steroid-sparing)
05
Phototherapy: PUVA (oral or topical), targeted excimer laser 308 nm
06
First-line systemic: acitretin 25-50 mg/day oral retinoid (most effective for PPP)
07
Methotrexate 15-25 mg weekly (especially with associated arthritis)
08
Biologics: spesolimab anti-IL-36R (FDA-approved for generalized pustular psoriasis), ustekinumab anti-IL-12/23
09
TNF inhibitors: adalimumab, etanercept (variable efficacy in PPP)
10
Apremilast PDE4 inhibitor 30 mg twice daily for moderate disease

Which Department to Visit?

You can visit our Dermatoloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.