Psoriasis of Hands and Feet including Palmoplantar Pustulosis

Authored by Dr Colin Tidy, 25 Jan 2013

Reviewed by:
Dr John Cox, 25 Jan 2013

Patient professional reference

Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Psoriatic Arthritis article more useful, or one of our other health articles.

Synonyms: psoriasis palmoplantaris, psoriasis palmaris et plantaris 

Psoriasis predominantly affecting the palms and soles takes two forms:

  • Erythematous scaly plaques typical of psoriasis elsewhere in the body.
  • More generalised thickening and scaling (keratoderma).

Palmoplantar pustulosis is a chronic inflammatory skin condition. It is considered by some to be a variation of psoriasis and occurs in patients with other types of psoriasis.[1] However, the nature of the link with psoriasis is unclear and there are significant differences. Neuroendocrine dysfunction of the sweat glands has been implicated in the pathogenesis.[2] See the 'Palmoplantar pustulosis' section at the end of this article.

There is a separate article on Psoriatic Nail Disease.

1.5% of the general UK population have psoriasis.[3] A proportion of these patients, usually with psoriatic lesions elsewhere, will have psoriasis involving the feet and hands.

  • Red scaly plaques.
  • Hyperkeratotic areas.
  • Central palm or weight-bearing areas of the soles.
  • Well demarcated.
  • Painful cracking and fissuring.
  • Hyperkeratotic eczema.
  • Tinea pedis.
  • Palmoplantar pustulosis (PPP) (see section below).

See also the separate article on Chronic Plaque Psoriasis.

Primary care management

  • Classical psoriatic lesions can be treated with a vitamin D ointment (calcipotriol/Dovonex® or tacalcitol/Curatoderm®) or dithranol (Dithrocream®/Micanol®).
  • In palm and sole psoriasis, both hyperkeratosis and inflammation are usually present and may require separate treatments:
    • Hyperkeratosis usually needs to be treated with a keratolytic agent such as 2% salicylic acid ointment BP.
    • This can be alternated morning and evening with a topical steroid (usually potent, due to the thick skin at this site).[4]

When to refer[4]

  • Where there is diagnostic uncertainty.
  • For further patient counselling and education.
  • Where appropriate initial treatment has failed.
  • Where there is significant occupational disability.

Further treatments

Further treatment options in secondary care include low doses of oral retinoids with Psoralen combined with ultraviolet A (PUVA) or UVB phototherapy, methotrexate, ciclosporin or acitretin.

Pain can restrict the use of hands or walking.

Psoriasis of the hands and feet tends to be persistent and, in some, quite resistant to treatment.

The cause of palmoplantar pustulosis (PPP) is unknown. It is probably autoimmune in origin as there is an association with other autoimmune diseases, particularly coeliac disease, thyroid disease and type 2 diabetes.[1]

PPP was thought to be a localised form of pustular psoriasis but about 10-20% of patients with PPP have psoriasis elsewhere. It is therefore now considered that they are distinct conditions with different genetic backgrounds.[1]


The condition occurs much more commonly in smokers and ex-smokers. It may run in families and rarely occurs in childhood. Gluten sensitivity and tonsillar streptococcal infection have been implicated in some cases.[5]


PPP typically presents as multiple sterile pustules on the palms and soles (initially yellowish fading to brown macular pinpoint lesions).

Palmoplantar pustulosis foot

Affected areas may become red, scaly and frequently painful. Eruptions of pustules occur unpredictably and may return repeatedly over years.

Differential diagnosis

Infected eczema - less defined, white vesicles rather than pustules, swabs often grow Staphylococcus aureus.

  • Acute pompholyx is an episodic form of eczema affecting the palms and soles with bullae formation, which frequently becomes infected.
  • Tinea pedis - commonly unilateral or asymmetrical erythema, scaling and pustules. Toe clefts and nails are usually involved.
  • Reiter's disease - gross palmar and plantar lesions may occur (keratoderma blennorrhagica) which are histologically indistinguishable from psoriasis. This also affects the mouth and penis.
  • Acrodermatitis continua of Hallopeau (ACH): a rare indolent form of psoriasis with sterile pustular changes and dactylitis affecting the distal digits and nails.[6]

Primary care management[1, 4, 7]

Evidence-based treatment for PPP is contentious. Those who claim that PPP is simply a variation of psoriasis believe that the condition should be managed as per the guidelines for psoriasis but there is no consensus on this.[7] Various treatments have been used but none is generally accepted as universally effective.[5] A Cochrane review highlighted methodological problems with the studies designed to differentiate between the efficacy of different approaches.[8]

  • Encourage general measures:
    • Good footwear made from natural fibres.
    • Avoidance of even minor trauma.
    • Waterproof dressings over fissured areas.
    • Resting the affected area where possible.
  • Emollients are important:
    • Apply thick greasy emollients to soften skin and prevent fissures.
    • Soak in warm water with emulsifying ointment.
    • Use salicylic acid ointment or urea cream to peel dead skin.
    • Wash with soap substitutes.
  • Potent topical steroid ointments - eg, clobetasol propionate - may be used twice daily for limited periods. High-potency steroids are required in order to penetrate the thick skin of the hands and feet. Occlusion with clingfilm or dressings can enhance penetration but should not be used for more than five days in a row.
  • Coal tar is messy but can be applied directly, often mixed into an ointment base.
  • Calcipotriol can be helpful - apply twice a day and do not cover.

When to refer[1, 4]

  • Referral is primarily for help with diagnosis and treatment, or if symptoms are particularly disabling.
  • Palms and soles are difficult sites to treat and palmar pustular psoriasis can be resistant to treatment so specialist advice may be required.

Further treatments

Further treatment options which dermatologists can use include:

  • Systemic retinoids - for example, acitretin, arotinoid ethyl ester.[9]
  • PUVA treatment to hands and feet (sometimes combined with systemic retinoids).[8]
  • Methotrexate.[1]
  • Etanercept.[10]


  • Pain from lesions and associated fissuring may be significant.
  • Walking and standing for long periods can exacerbate lesions on the soles of the feet.
  • Manual activity can be uncomfortable if the hands are affected.
  • Occupational and functional disability secondary to above.
  • Pustulotic arthro-osteitis (sterile inflammatory osteitis of the sternoclavicular region) is a rare but severe complication of palmar pustulosis.[11]


The condition tends to be chronic and poorly responsive to treatment.[1]

Further reading and references

  1. Palmoplantar Pustulosis, DermNet NZ

  2. de Waal AC, van de Kerkhof PC; Pustulosis palmoplantaris is a disease distinct from psoriasis. J Dermatolog Treat. 2011 Apr22(2):102-5. Epub 2010 Aug 5.

  3. Gelfand JM, Weinstein R, Porter SB, et al; Prevalence and treatment of psoriasis in the United Kingdom: a population-based study. Arch Dermatol. 2005 Dec141(12):1537-41.

  4. Psoriasis - General Management, British Association of Dermatologists (2008)

  5. Mrowietz U, van de Kerkhof PC; Management of palmoplantar pustulosis: do we need to change? Br J Dermatol. 2011 May164(5):942-6. doi: 10.1111/j.1365-2133.2011.10233.x.

  6. Bordignon M, Zattra E, Albertin C, et al; Successful treatment of a 9-year-old boy affected by acrodermatitis continua of Photodermatol Photoimmunol Photomed. 2010 Feb26(1):41-3.

  7. Diagnosis and management of psoriasis and psoriatic arthritis in adults; Scottish Intercollegiate Guidelines Network - SIGN (October 2010)

  8. Marsland AM, Chalmers RJ, Hollis S, et al; Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev. 2006 Jan 25(1):CD001433.

  9. Shan SJ, Li YH, Zhang G, et al; Treatment of palmoplantar pustulosis with arotinoid ethylester. Eur J Dermatol. 2009 Sep-Oct19(5):474-7. Epub 2009 Jun 5.

  10. Bissonnette R, Poulin Y, Bolduc C, et al; Etanercept in the treatment of palmoplantar pustulosis. J Drugs Dermatol. 2008 Oct7(10):940-6.

  11. Hayama K, Inadomi T, Fujisawa D, et al; A pilot study of medium-dose cyclosporine for the treatment of palmoplantar Eur J Dermatol. 2010 Nov-Dec20(6):758-62. Epub 2010 Nov 4.

I'm about to start my 1st methotrexate dose, I have palmar psoriasis, also on my elbows and groin  but that's it, since the topical aren't working, I'm starting mtx on a dose of 15 mg per week!..I've...

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