1
DEFINITION
Palmoplantar pustulosis (PPP) is a chronic pustular dermatosis which localized on the palms and soles
only.
High resistance to treatment and a high recurrence rate are characteristic.
2
ETIOLOGY
The exact cause is unknown Possible mechanism of pustule formation :
an imbalance of protease/antiprotease system in the skin
Decreased antileukoprotease (elafin/SKALP) activity
3
RISK FACTORS
• Heavy smoking (>20 cigarettes/day)• Tonsilitis• Hyper/hypothyroidism• Seasonal factors (high humidity and high
temperature)
CLINICAL FEATURES
Symptoms Stinging, burning → itching Eruptions come and go, in waves
Skin Lesions Pustules in stages of evolution 2–5 mm Deep-seated, yellow develop into dusky-red
macules and crusts Present in areas of erythema and scaling or normal
skin
• Location• Limited to palms and soles, may be only a localized patch
on the sole or hand• Or involve both hands and feet with a predilection of
thenar and hypothenar flexor aspects of fingers, • heels, and insteps• acral portions of the fingers and toes
Groups of pustules measuring 2 to 4 mm in diameter occur on erythemathous skin on pamls and soles. Both feet and both hands are normally affected symmetrically but can also be found on one side only
As pustules become older, their yellow color changes to dark brown
In untreated PPP ; the lesions show various shades of color
Dried pustules are shed within approximately 8 to 10 days
In severe eruptions ; pain and the inability to stand, walk or do manual work may greatly reduce the quality of life
Lession may occasionally spread beyond the predilection sites, and pustules may appear on the wrists. Within several days after pustules formation, lesions dry, flatten, and acquire a brownish color. May be followed by ezcematous changes with scaling and fissuring
Pustules that are partially confluent on the palm of a 28-year-old female. Pustules are sterile and pruritic, and when they get larger, become painful.
DIAGNOSIS
• HISTORY TAKING• PHYSICAL EXAMINATION• HISTOPATOLOGY
HISTOPATOLOGY
Histologically, there is a spongioform pustule and a moderate lymphohistiocytic infiltrate
DIFFERENTIAL DIAGNOSIS
TINEA MANUM• Chronic dermatophytosis
of the hand(s)• Often unilateral, most
commonly on the dominant hand
• Usually associated with tinea pedis
DERMATITIS NUMMULAR
• Nummular eczema is a chronic, pruritic, inflammatory dermatitis
• Occurring in the form of coin-shaped plaques composed of grouped small papules and vesicles on an erythematous base
CONTACT DERMATITIS
Irritant contact dermatitis (ICD) is caused by a chemical irritant;
Allergic contact dermatitis (ACD) by an antigen (allergen) that elicits hypersensitivity reaction.
Fitz’s Patrick
TREATMENT
The disease is commonly resistant to treatment
Acitretin is generally extremely effective at a dose of 0.5-1
mg/kg/day, although rebound occurs more quickly than with
etretinate
Low-dose cyclosporine in doses ranging from 1.25 to 5
mg/kg/day has also been very effective, but it is not suitable
for long-term treatment.
Andrew’s Disease of The Skin
The clinical course of PPP is highly unpredictable. In patient with active disease of fresh pustules at the beginning of treatment relapse within a few days after cessation of any therapy or dose-reduction is highly likely.
In phases of remission fewer pustules are produced but the skin may remain erythematous hyperkeratotic, sometimes resembling eczema.
PROGNOSIS
