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.

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

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 25 mm
Deep-seated, yellow develop into duskyred 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.

TREATMENT

Fitzs Patrick

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.
Andrews Disease of The Skin

PROGNOSIS
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.