Pustular Psoriasis

Aka: Pustular Psoriasis, Palmoplantar Pustulosis, Palmoplantar Pustular Psoriasis, Pustulosis of Palms and Soles, Acute Generalized Exanthematous Pustulosis, von Zumbusch variant

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II. Pathophysiology

  1. Chronic inflammatory skin disease
  2. Likely represents a distinct condition from Psoriasis

III. Epidemiology

  1. Occurs most often in middle aged adults

IV. Risk Factors

  1. Most commonly triggered by medications that have been recently started (86% of cases)
    1. Penicillins
    2. Macrolides
    3. Quinolones
    4. Sulfonamides
    5. Terbinafine
    6. Diltiazem
  2. Other factors
    1. Tobacco Abuse
    2. Thyroid disease
    3. Emotional stress
    4. TNF Inhibitor
    5. Streptococcus infection

V. Symptoms

  1. Burning pain and Pruritus on the palms and soles
  2. Painful ambulation due to sole lesions

VI. Signs

  1. Multiple pin-sized, sterile Pustules on red base on the palms and soles without Plaques
    1. Sterile Vesicles and Pustules (2-5 mm) on the palms and soles
    2. Lesions evolve into yellowish-brown to red Macules
  2. Associated findings
    1. Hyperkeratosis
    2. Scaling
    3. Skin fissures
  3. Provocative factors
    1. Metal Allergic Contact Dermatitis

VII. Labs

  1. Potassium Hydroxide stain (KOH Preparation)
    1. Exclude Tinea Pedis or Tinea Manum
  2. Skin biopsy
    1. Confirms diagnosis (not required)
    2. Biopsy should be done if Acute Generalized Exanthematous Pustulosis is suspected

VIII. Differential Diagnosis

  1. Secondary Skin Infections
  2. Widespread Impetigo
  3. Fungal infections
    1. Severe Candidiasis
    2. Tinea Manum
    3. Tinea Pedis
  4. Psoriasis
  5. Dyshidrotic Eczema
  6. Dermatitis Herpetiformis

IX. Associated Conditions

  1. Psoriasis
    1. Unclear if Palmoplantar Pustulosis is Psoriasis variant or a distinct condition
  2. Acute Generalized Exanthematous Pustulosis (von Zumbusch variant)
    1. Severe, acute, life-threatening sub-type develops in <2 weeks
    2. Biopsy intact Pustule to exclude

X. Management

  1. Similar to Psoriasis management starting with high potency Topical Corticosteroids
    1. Typically managed by dermatology
  2. General measures
    1. Skin Lubricants
    2. Avoid topical irritants and allergans
    3. Tobacco Cessation
  3. First-line agents
    1. High potency Topical Corticosteroids (may be ineffective)
    2. Oral Retinoids
    3. Calcipotriene (Donovex)
    4. Photochemotherapy (e.g. PUVA)
  4. Second-line agents
    1. Cyclosporine
    2. Methotrexate

XI. References

  1. Fitzpatrick (1992) Color Atlas Dermatology, p. 52-3
  2. Pesqueira (2019) Am Fam Physician 100(9): 579-80 [PubMed]

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