Psoriasis palmaris et plantaris (overview) L40.3

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)

About 10-15% of psoriatics have palmo-plantar infestation.

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 defined, erythematous plaques on Palmae and Plantae. The efflorescences within these plaques differ depending on the variant:

• Keratotic type (most common type): In the middle of the sharply defined erythematous plaques, a severe hyperkeratosis is evident. If these plaques persist for a long time, the loss of elasticity under mechanical stress leads to deep, painful, bleeding rhagades. The hyperkeratotic plaques are found particularly in the area of the thenar and hypothenar, on the soles of the feet in the area of the pressure-loaded areas.
• Pustular type (Königsbeck-Barber type): Sharply defined erythema plaques with numerous white to yellowish clouded sterile pustules and clear, so-called dyshidrotic vesicles. The inguinal relief is lost in the focus, the skin appears smooth atrophic. The foci are usually found in the palm of the hand and in the area of the arch of the foot in the areas not exposed to pressure. It may be doubted that the pustular type Königsbeck-Barber can be separated from the rare acute pustulosis palmaris et plantaris.
• Dyshidrotic type: In the midst of the psoriatic plaques there are numerous clear dyshidrotic vesicles at the level of the skin, mostly pinhead-sized. The appearance of the vesicles is intermittent.

S.u. Psoriasis vulgaris.

Depending on the variant:

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

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

• Dry keratotic plaque type:
  • Keratolytic, chemical and physical measures are in the foreground in this eminently chronic, low inflammatory plaquepsoriasis. Initially, highly concentrated (10-20%) pure salicylic acid ointments, salicylic acid/cooking salt and urea ointment combinations can be highly effective, some with and some without occlusion R227 R107. The ointments should be applied in a thick layer on the palms of the hands and feet. Occlusion is best achieved with a disposable plastic glove (prescribe as a disposable product, cut off the fingers of the glove, put a cotton glove over it) or with occlusive foil (household foil is sufficient). Leave occlusion for 2 times 2-4 hrs/day at first, increasing the occlusion time later is possible.
  • An alternative to salicylic acid ointments are salicylic acid gels, which some patients find pleasant R216. External, possibly occlusive application of Tazarotene (e.g. Zorac). After the occlusive phase mechanical removal of the adherent keratoses as soon as possible. This can be done on an inpatient basis by experienced nursing staff using a large blunt curette. Cave! Do not set any injuries! On an outpatient basis, the patient 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 keratolytic intensive therapy can be intensified by alternate occlusive measures with a glucocorticoid ointment (e.g. Dermatop Fatty Ointment, Ecural Ointment) (initial 2 times/day); duration of occlusion 2-4 hours each time. After complete keratolysis, a largely normal-configured skin with lesional erythema remains.
  • For stabilization and further improvement of the condition, if necessary, careful PUVA-bath therapy can be applied (the skin is very UV-sensitive after keratolysis; danger of burns!). Local therapy with a 10% urea saline ointment R107. Keratolysis treatments must be repeated at intervals of 7-10 days. A combination with calcipotriol or tazarotene is possible, but the externals should only be applied after UV irradiation.
  • Rhagades: Painful, often deep rhagades are common. Occurs in tension lines of the palms due to inflexibility of the hyperkeratotic skin (skin breaks under mechanical stress like dry leather!). Treatment by applying glucocorticoid ointment such as 0.25% prednicarbate (e.g. Dermatop Fatty Ointment). Covering with hydrocolloid foil (e.g. Varihesive extra thin), leave for 12 hours, then remove and carefully flatten hyperkeratotic edges with a sharp curette (e.g. Fa. Stiefel). Repeat glucocorticoid occlusion for 12 hours, repeat the procedure. Then apply wound ointments containing polyvidone (e.g. Betaisodona ointment). Even long-term persistent rhagades heal under this therapy. The patient becomes pain-free and can put "normal" weight on the palms of his hands and soles of his feet. Analogous procedure for rhagades at the fingertips. Occlusive measures (preferably with hydrocolloid foils) 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). Occlusion duration 2 times 4 hours/day. Therapy over several days.
  • In case of persistent shear activity, the local ointment therapy has to be supplemented by a local PUVA therapy (as PUVA bath therapy). A combination with Calcipotriol or Tazarotene is possible, but the Externa should only be applied after the photochemotherapy. Accompanying local care 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 (resistance to therapy):
  • If the local measures do not have sufficient effect, an additive systemic therapy should be applied. In this case the indication for systemic therapy is less dependent on the absolute extent or the acuteity of the skin symptoms. Rather, the personality profile as well as the job-related, personal requirement profile for intact hands and feet must be included in this decision (example: dentist, craftsman, standing professions, etc.)

As a matter of principle, systemic therapy should be initiated in palmo-plantar psoriasis, in the case of significant impairment of haptic perception and disturbances of tactile functions, which often interfere with normal work processes.

• Parallel to external measures Acitretin (Neotigason) 0.5 mg/kg bw/day p.o. Adjust maintenance dose individually, if possible beyond stronger adverse events. Experience shows that dosages are 0.1 mg/kg bw/day p.o.
• Treatment with fumaric acid esters (Fumaderm®/Scilarence®) has proven effective in cases of insufficient effect or in more exudative forms. The dosage can be significantly lower in the dry keratotic plaque form than in the exudative or psutolar forms.
• In exudative forms, with pronounced resistance to therapy and high shear activity, the use of methotrexate (e.g. Lantarel) should be considered. Initial dosage at 15 mg/week p.o., maintenance dose depending on the acuteity of the symptoms generally 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 selected under strict clinical monitoring.
• If minor skin symptoms are 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).
• If the effect is insufficient or in case of a fatal therapy situation (exceeding of a cumulative total dose, limiting hepatoxic side effects, excessive pre-damage of the liver) Etanercept can be used as a second-line therapy (level of evidence D). Due to the considerable costs of this therapy, it is recommended to obtain a second opinion in a designated paraxy centre!
• Alternatively other biologicals 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.

Palmoplantar psoriasis, as a congenital disease, represents a particular challenge in occupational dermatological assessment. S.a. 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.