Psoriasis palmaris et plantaris (overview) L40.3

Clinical monotopic variant or partial manifestation of psoriasis with manifestation on the hands and/0r the feet.

Depending on the clinical appearance, a distinction is made between palmaris and/or plantaris psoriasis:

• Psoriasis palmaris/plantaris plaque type (dry keratotic type - 80% of patients)
• Psoriasis palmaris/plantaris Pustular type(Psoriasis pustulosa palmaris et plantaris), also called Königsbeck-Barber type
• Psoriasis palmaris/plantaris Dyshidrotic type (Psoriasis palmaris et plantaris, dyshidrotic type)
• Psoriasis palmaris/plantaris mixed type (Psoriasis palmaris et plantaris with plaques, blisters and/or pustules)

Approximately 10-15% of psoriatic patients have palmo-plantar involvement.

Ultimately unknown. Chronic mechanical, osmotic and chemical stress seems to be a contributory and maintaining factor of palmo-plantar psoriasis with an appropriate disposition. S.a. Psoriasis palmaris et plantaris, occupational dermatological relevance.

Sharply demarcated, erythematous or skin-colored-white plaques on palmae and plantae. The efflorescences within these plaques differ according to the variant:

• Keratotic type (most common type): In the midst of the sharply demarcated erythema plaques, a vigorous hyperkeratosis is imprinted. Prolonged persistence of these foci results in deep, painful, bleeding rhagades due to loss of elasticity under mechanical stress. The hyperkeratotic plaques are found especially in the thenar and hypothenar areas, and on the soles of the feet in the areas exposed to pressure.
• Pustular type (Königsbeck-Barber type): Sharply demarcated erythema plaques with numerous white to yellowish opacified, sterile pustules and clear, so-called dyshidrotic vesicles. The groin relief is lost in the foci, and the skin appears smoothly atrophic. The foci are usually found in the hollow of the hand and in the arch of the foot in the non-pressure areas. It may be doubted whether the Königsbeck-Barber pustular type can be separated from the rare acute pustulosis palmaris et plantaris.
• Dyshidrotic type: In the midst of the psoriatic plaques are numerous clear dyshidrotic vesicles, usually pinhead-sized, located at the skin level. The appearance of the vesicles is intermittent, sometimes combined with pustules.

S.u. Psoriasis vulgaris.

Depending on the variant:

• Pustular Bacterid Andrews
• Impetiginized dyshidrotic hand eczema (see dermatitis, dyshidrotic
• Hyperkeratotic rhagadiform eczema
• Calluses (pressure calluses)
• Keratosis palmoplantaris
• Arsenic keratoses
• Tinea manuum or tinea pedum
• Papulosquamous syphilid
• Reiter's syndrome
• Lichen planus.

Painful rhagades, nail infestation with painful paronychia (see psoriasis of the nails below), nail dystrophies, psoriatic arthritis of the finger or wrist joints.

• Dry keratotic plaque type:
  • In this eminently chronic, low-inflammatory plaque psoriasis, keratolytic, chemical and physical measures are the main focus. Initially, highly concentrated (10-20%) pure salicylic acid ointments, salicylic acid/boiled salt and urea ointment combinations can be well effective, sometimes with, sometimes without occlusion (Rp.: salicylic acid ointment (W/O); urea 10%/boiled salt 10% ointment (NFA). Here, the ointments should be applied in a thick layer to the palms/feet. Occlusion is best done with disposable plastic glove (prescribe as disposable, cut off fingers of glove, put cotton glove over it) or with occlusive foil (household foil will do). Initially leave occlusion for 2 times 2-4 hrs/day, increase of occlusive time is possible later.
  • An alternative to salicylic acid ointments are salicylic acid gels, which some patients find pleasant R216. External, occlusive application of tazarotene (e.g. ^Zorac®) if necessary. After the occlusive phase, mechanical ablation of the adherent keratoses as soon as possible. Inpatients can be treated with a large blunt curette by experienced nursing staff. Caution! Do not set any injuries! Outpatients can rub off the pre-treated keratoses with a pumice stone, preferably after a 15-minute warm hand-foot bath in a soapy solution (curd soap is recommended). The intensive keratolytic therapy can be intensified by alternating occlusive measures with a glucocorticoid ointment (e.g. Dermatop fat ointment, Ecural ointment) (initially 2 times/day); occlusion duration 2-4 hrs in each case. After complete keratolysis, largely normal skin with lesional erythema remains.
  • For stabilization and further improvement of the condition, cautious PUVA bath therapy may follow (the skin is very sensitive to UV after keratolysis; risk of burns!). Local therapy with a 10% urea saline ointment R107. Keratolysis treatments must be repeated at intervals of 7-10 days. Combination with calcipotriol or tazarotene is possible, but the externals should be applied only after UV irradiation.
  • Rhagades: Painful, often deep rhagades are common. Occur in tension lines of the palms due to inflexibility of hyperkeratotic skin (skin breaks under mechanical stress like dry leather!). Treatment by spreading glucocorticoid ointment such as 0.25% prednicarbate (e.g. Dermatop Fatty Ointment). Cover with hydrocolloid film (e.g. Varihesive extra thin), leave for 12 hours, finally peel off and carefully flatten hyperkeratotic edges with sharp curette (e.g. Fa. Stiefel). Again glucocorticoid occlusive measure for 12 h, repeat procedure. Subsequently apply wound ointments containing polyvidone (e.g. Betaisodona ointment). Under this therapy, even rhagades that have persisted for a long time heal. The patient becomes pain-free and can put "normal" weight on the palms of the hands and soles of the feet. Analogous procedure for rhagades on the fingertips. Occlusive measures (preferably with hydrocolloid sheets) are essential.
• Pustular and/or dyshidrotic type:
  • Variable thrust and inflammatory activity. External therapy in the acute stage with strong glucocorticoid ointments such as 0.05% clobetasol (e.g. Dermoxin ointment) or 0.1% mometasone (e.g. Ecural ointment) under hourly occlusion (see above). Duration of occlusion 2 times 4 hours/day. Therapy over several days.
  • In case of persistent relapsing activity, local ointment therapy should be supplemented by local PUVA therapy (as PUVA bath therapy). A combination with calcipotriol or tazarotene is possible, but the externals should be applied only after photochemotherapy. Accompanying care local measures (e.g. ash base ointment, Linola fat). Intercept relapses occurring under this therapy with glucocorticoid ointment (e.g. Ecural ointment) or glucocorticoid tincture (e.g. Ecural solution, Dermatop tincture).
• Pustular and/or dyshidrotic type (therapy resistance):
  • If local measures are insufficiently effective, additive systemic therapy should be used. In this case, the indication for systemic therapy is based less on the absolute extent or the acute nature of the skin symptoms. Rather, the personality profile as well as the occupational, personal requirement profile for intact hands and feet must be included in this decision (example: dentist, craftsman, standing professions, etc.).

Basically, in palmo-plantar psoriasis, if there is significant impairment of haptic perception and disturbances of tactile functions, which often interfere with normal work processes, systemic therapy should be initiated.

• In parallel with external measures, acitretin (neotigasone) 0.5 mg/kg bw/day p.o. Adjust maintenance dose individually, preferably beyond more severe UAW. Doses based on experience are 0.1 mg/kg bw/day p.o.
• If the effect is insufficient or in more exudative forms, treatment with fumaric acid esters (Fumaderm®/Scilarence®) has proven effective. The dosage can be significantly lower in dry keratotic plaque forms than in exudative or psutulous forms.
• In exudative forms, with pronounced resistance to therapy and high relapse activity, the use of methotrexate (e.g. Lantarel) should be considered. Initial dosage at 15 mg/week p.o., maintenance dose depending on the acuity of the symptomatology i.a. at 2.5-5.0 mg/week p.o. For colleagues experienced in this therapy, a combination of fumaric acid esters and methotrexate can be chosen with strict clinical monitoring.
• If mild skin symptomatology is accompanied by clinically relevant and disabling arthritic symptoms of the hand and/or finger joints, the additive use of methotrexate (15-25 mg/week p.o.) should be considered (fumarates are less effective in this constellation).
• In case of insufficient effect or in case of a complicating therapy situation (exceeding of a cumulative total dose, limiting hepatoxic side effects, excessive pre-damage of the liver) etanercept can be used as second-line therapy (evidence level D). Due to the considerable costs of this therapy, it is recommended to obtain a second opinion in a designated paraxis center, if necessary!
• Alternatively, other biologics can be used.

With dyshidrotic concomitant component nicotine abstinence.

Patients with palmo-plantar psoriasis suffer from a more severe limitation of their quality of life than patients with moderate psoriasis vulgaris. This concerns problems with mobility, self-care and other everyday activities.

As a congenital disease, palmoplantar psoriasis represents a particular challenge in occupational dermatological assessment. See also Psoriasis palmaris et plantaris, occupational dermatological relevance.

1. Angelovska I et al (2014) Palmoplantar psoriasis at work: A case series from practice in consideration of the S1 guideline for occupational dermatological assessment of psoriasis.JDDG 12:697-706
2. Asumalahti K et al (2003) Genetic analysis of PSORS1 distinguishes guttate psoriasis and palmoplantar pustulosis. J Invest Dermatol 120: 627-632
3. Chung J et al(2014) Palmoplantar psoriasis is associated with greater impairment of health-related quality of life compared with moderate to severe plaque psoriasis. J Am Acad Dermatol 71:623-632.
4. Kumar B et al (2002) Palmoplantar lesions in psoriasis: a study of 3065 patients. Acta Derm Venereol 82: 192-195.
5. Pettey AA et al (2003) Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice. J Am Acad Dermatol 49: 271-275.
6. Weinberg JM (2003) Successful treatment of recalcitrant palmoplantar psoriasis with etanercept. Cutis 72: 396-398.
7. Weißenseel P (2016) Pustular psoriasis. Dermatologist 67: 445-453.