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- Presentation
Diagnosis and Treatment of Palmar and Plantar Psoriasis and Pustulosis
Description
The talk reviews diagnosis and treatment of palmar and plantar psoriasis, separating non-pustular plaque-type disease from palmoplantar pustulosis because they can be difficult to distinguish and may overlap with dermatitis, tinea, infection, drug reactions, or contact allergy. Dermoscopy can help: psoriasis often shows hairpin/dotted vessels and white scale, while dermatitis more often shows focal punctate vessels and mixed white-yellow scale. The speaker emphasizes that multiple processes may coexist, so patch testing and evaluation for infection or irritant/allergic exposures can be important. For non-pustular palmar plantar psoriasis, most psoriasis therapies can work, including topicals, oral agents, phototherapy, and biologics, with IL-17 and IL-23 inhibitors having the best evidence so far; smoking is a key trigger and cessation is important. Palmoplantar pustulosis is less common, more impactful, and harder to treat; it is not the same as generalized pustular psoriasis and usually lacks IL-36 mutations. Triggers are similar but infection and medications are especially important in some populations. No single therapy is reliably effective, TNF inhibitors may actually trigger or worsen disease, and phototherapy is less useful. Early data suggest potential benefit from IL-17/IL-23 agents, bimekizumab, apremilast, and possibly JAK/TYK2 inhibitors, while cyclosporine remains a useful rapid rescue option. Clinicians should monitor carefully because biologics can both treat and provoke palmoplantar disease.
View moreConclusions
- Palmoplantar psoriasis is common, highly impactful, and often difficult to distinguish from dermatitis or mixed dermatoses.
- Dermoscopy can help differentiate palmoplantar psoriasis from dermatitis, but clinical overlap and coexisting conditions are common.
- Non-pustular palmoplantar psoriasis can respond to many standard psoriasis therapies, with IL-17 and IL-23 inhibitors having the strongest evidence.
- Smoking is an important trigger and cessation target, though early prevention may be more important than treatment after disease has developed.
- Palmoplantar pustulosis is a distinct, less common, and often more treatment-resistant disease with major quality-of-life effects.
- There is no single reliably effective first-line therapy for palmoplantar pustulosis, and trial results are limited by high placebo responses and inconsistent outcome measures.
- TNF inhibitors can trigger or worsen palmoplantar pustulosis, especially in patients with rheumatologic disease or IBD.
- Biologics can be a double-edged sword in palmoplantar disease because they may both treat and provoke flares.
- IL-17 and IL-23 pathway agents show the most promise overall, but benefits are often modest and not consistently superior to placebo in pustular disease.
- Bimekizumab, apremilast, and upadacitinib show encouraging early signals, suggesting that JAK/TYK2 and other nonbiologic approaches may become more useful options.
- Cyclosporine remains an important rapid rescue therapy for difficult palmoplantar disease.
- More research is needed, especially better trials and better outcome measures, to identify consistently effective treatments for PPP.
- Huang 2024. PP: network meta-analysis comparing 16 randomized trials, 4,118 patients, and 9 biologics/small molecules; secukinumab ranked first for PPPGA 0/1 at 12–16 weeks.
- Kim SR, Choi YG, Jo SJ. 2024 British Journal of Dermatology citation (PPP smoking cessation/prospective uncontrolled study of 63 adult smokers with PPP). PMID: 38534203.
- Passeron et al. JAMA Dermatology, 2024. Bimekizumab open-label case series in 21 patients with palmoplantar pustular psoriasis/pustular psoriasis.
- Terui T. et al. AAD 2024 late-breaking abstract. Apremilast study in Japanese PPP.
- Huang 2024. PPP NMA: Palmoplantar Pustular Psoriasis network meta-analysis of 7 randomized trials and 596 patients.