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Concept: Pustulosis palmaris et plantaris


Palmoplantar pustulosis is characterized by sterile pustules with hyperkeratosis, erythema, scaling, and fissuring on the palms and soles.(1) It has been reported to be more frequent in middle-aged women, smokers, and diabetic patients(2) , and it is increasingly reported as a paradoxical reaction to antitumor necrosis factor alpha (anti-TNF) biological agents.(3, 4.) It can present itself alone (PPP), or in association with psoriasis vulgaris (palmoplantar pustular psoriasis, PPPP).

Concepts: Ultraviolet, Tumor necrosis factor-alpha, Psoriatic arthritis, Psoriasis, Etanercept, Pustulosis palmaris et plantaris, Ustekinumab, Adalimumab


BACKGROUND: The International Psoriasis Council in 2007 considered palmoplantar pustulosis (PPP) as a separate condition from psoriasis, despite the presence of certain phenotypes common in both diseases. OBJECTIVE: To describe and compare demographic and clinical characteristics among PPP and palmoplantar plaque psoriasis. METHODS: Retrospective case-series study from 2005 to 2010. The following data were obtained: age, sex, family history, smoking habits, nail involvement, joint involvement, disease duration, lesions morphology (plaque or pustular), histological diagnosis, co-morbidities, and PGA score for extra-palmoplantar lesions. Sample size calculation indicated that 80 patients, 40 patients for each group (palmoplantar plaque psoriasis and PPP) were needed to see clinically relevant differences between groups. RESULTS: Ninety patients were selected: 51 had palmoplantar plaque psoriasis and 39 had PPP. No statistically significant differences were registered between patients affected by PPP and palmoplantar plaque psoriasis as regards age at the onset of the disease (48 vs. 44 years; p 0.4), disease duration (6 vs. 10 years; p 0.1), family history of psoriasis (28.2% vs. 33.3%; p 0.7), concomitant arthritis (25.6% vs. 25.5%; p 1.0), or smoking habits (54.1% vs. 41.2%; p 0.2). We observed a female predominance (p 0.01) and a lesser frequency of nail involvement (p 0.03) in patients affected by PPP. CONCLUSIONS: Our data suggest a close relationship between PPP and psoriasis. The existing data concerning epidemiology, clinical presentation, genetics, histopathology and pathogenesis do not permit a clear distinction between these two entities, which seem to coincide in many aspects. PPP appears to have a marked predilection among female smokers.

Concepts: Epidemiology, Disease, Statistics, Statistical significance, Anatomical pathology, Psoriatic arthritis, Psoriasis, Pustulosis palmaris et plantaris


There is a controversy surrounding the existence of palmoplantar pustulosis (PPP) and palmoplantar pustular psoriasis (PPPP) as separate clinical entities or as variants of the same clinical entity. We used gene expression microarray to compare gene expression in PPP and PPPP.

Concepts: DNA, Gene expression, Ultraviolet, Molecular biology, DNA microarray, Psoriatic arthritis, Psoriasis, Pustulosis palmaris et plantaris


Pustular psoriasis (PP) is a group of inflammatory skin conditions characterized by infiltration of neutrophil granulocytes in the epidermis to such an extent that clinically visible sterile pustules develop. Because of clinical co-incidence, PP is currently grouped with psoriasis vulgaris (PV). However, PP and PV are phenotypically different, respond differently to treatments, and seem to be distinct on the genetic level. In contrast to PV, the phenotypes of PP are not well defined. Descriptions of each form of PP are discordant among standard dermatology textbooks [1-5], encumbering the collection of phenotypically well-matched groups of patients as well as clinical trials. The European Rare and Severe Psoriasis Expert Network (ERASPEN) was founded to define consensus criteria for diagnosis, deeply phenotype large groups of PP patients, analyse the genetics and pathophysiology and prepare for prospective clinical trials. This work reviews historical aspects of these conditions, new genetic findings and presents our initial considerations on the phenotypes of PP and a consensus classification of clinical phenotypes that will be used as a baseline for further, prospective studies of PP. Generalized Pustular Psoriasis (GPP) is defined as primary, sterile, macroscopically visible pustules on non-acral skin (excluding cases where pustulation is restricted to psoriatic plaques). GPP can occur with or without systemic inflammation, with or without PV and can either be a relapsing (>1 episode) or persistent (> 3 months) condition. Acrodermatitis continua of Hallopeau (ACH) is characterized by primary, persistent (> 3 months), sterile, macroscopically visible pustules affecting the nail apparatus. Palmoplantar pustulosis (PPP) has primary, persistent (> 3 months), sterile, macroscopically visible pustules on palms and/or soles and can occur with or without PV. This article is protected by copyright. All rights reserved.

Concepts: Inflammation, Eczema, Psoriatic arthritis, Psoriasis, Pustulosis palmaris et plantaris, Generalized pustular psoriasis


Since 2007, palmoplantar pustulosis (PPP) has been classified as a separate entity and not a clinical variant of psoriasis despite the presence of certain phenotypes common in both diseases.(1) We read with interest the review by Misiak-Galazka et al., and we found that even after the extensive work (inclusion of 65 articles), some relevant data are missing.(1-3) The clue question remains the following: Is palmoplantar pustulosis (PPP) closely related to psoriasis or is PPP a separate condition? Herein we will systematically review the literature searching for frequency of psoriasis in PPP patients and we will discuss new genetic insights that connect PPP and psoriasis vulgaris. This article is protected by copyright. All rights reserved.

Concepts: Following, Debate, English-language films, All rights reserved, Psoriasis, Pustulosis palmaris et plantaris, Copyright, Entity


Palmoplantar pustulosis is characterized by a chronic eruption of sterile pustules on palms and soles. The disease affects mainly women in the sixth and seventh decade of life. Some authors consider palmoplantar pustulosis a separate entity, whereas others consider it a condition in the spectrum of psoriasis. Aim of this study was to summarize the most recent data about PPP which aimed at establishing the nosological position of palmoplantar pustulosis. A systematic search of published literature was carried out. General characteristics of patients with PPP in different populations were present. We reviewed histological, immunological and genetic studies, as well as treatment options for PPP. PPP presents with clinical features, which are not present in psoriasis; however, the common coexistence of psoriasis vulgaris and/or positive family history for psoriasis indicates at least a close relationship between PPP and psoriasis. At present, there are not sufficient data to exclude PPP from psoriasis group.

Concepts: Medicine, Genetics, Interpersonal relationship, Psoriasis, Pustulosis palmaris et plantaris, Entity



The coexistence of psoriasis arthritis (PsA) and psoriasis vulgaris in about 20% of patients with psoriasis leads to a need for rheumatologic-dermatologic team work. We summarise the role of dermatologists in assessment of the skin in psoriasis. Chronic plaque psoriasis must be differentiated from other subtypes such as generalised pustular psoriasis (GPP) or palmoplantar pustulosis (PPP). Therapeutic management is based on the evaluation of the disease severity. Quantitative scoring of skin severity includes calculation of the Psoriasis Area and Severity Index (PASI), body surface area (BSA) as well as the Dermatology Life Quality Index (DLQI). These scoring systems do not replace the traditional dermatologic medical history and physical examination of the patient. The skin should be examined for additional skin diseases; moreover, patients should be monitored for comorbidity, most importantly PsA and cardiovascular comorbidity.

Concepts: Medicine, Ultraviolet, Hospital, Psoriatic arthritis, Psoriasis, Psoriasis Area Severity Index, Pustulosis palmaris et plantaris



Abstract Psoriasis is a chronic skin disorder that affects 1% to 3% of the general population worldwide. Streptococcal infection, especially streptococcal pharyngitis, has been shown to be a significant trigger of psoriasis in some patients, possibly by sensitizing T cells to keratin epitopes in the skin. Due to the role of the palatine tonsils as an immunological organ that may generate autoreactive T cells, tonsillectomy has been investigated as a treatment for psoriasis. Tonsillectomy originally gained acceptance in Japan as a treatment for palmoplantar pustulosis, a condition that shares features with pustular psoriasis. Subsequently, tonsillectomy has been used for the treatment of plaque psoriasis and guttate psoriasis. Recently, the first randomized, controlled clinical trial of tonsillectomy was performed. Here, we review the available evidence for the benefit of tonsillectomy as a treatment for palmoplantar pustulosis and psoriasis. We also discuss molecular studies aimed at understanding the role of tonsils in skin disease.

Concepts: Clinical trial, Cutaneous conditions, Skin, Psoriasis, Pustulosis palmaris et plantaris, Tonsil