What are the other Names for this Condition? (Also known as/Symptoms)

• Psoriasis of the Palms and Soles

What is Palmoplantar Psoriasis? (Definition/Background Information)

• Palmoplantar Psoriasis is an uncommon subtype of psoriasis, which is a common chronic inflammatory skin disease that develops from a genetic defect. The condition causes the epidermis to grow abnormally, resulting in the formation of skin lesions. Psoriasis can run in the families but is not  contagious
• Palmoplantar Psoriasis is a chronic condition that is characterized by itchy and stinging red patches on the hand palms and feet soles. The condition is more common in middle-aged and older women. Palmoplantar Psoriasis may precede psoriasis vulgaris or develop as part of widespread psoriasis
• The signs and symptoms of Palmoplantar Psoriasis may get better and worse over a period of time (several years); they tend to typically “come and go” and may be termed as recurrent episodes. The presentations may also vary from one individual to another and even within the same individual
• Palmoplantar Psoriasis, like all psoriasis, is incurable. However, the extent and activity of the condition may be controlled using medications and other treatment measures, including by bringing about certain lifestyle improvements. The condition may also go into a state of remission, meaning that there may periods when the skin remains normal
• The prognosis of Palmoplantar Psoriasis depends upon its severity and response to treatment. However, it is a lifelong persistent condition that needs to be regularly monitored and treated symptomatically. Severe cases of Palmoplantar Psoriasis can significantly affect one’s quality of life

Who gets Palmoplantar Psoriasis? (Age and Sex Distribution)

• Palmoplantar Psoriasis usually affects adults more than children. The period of manifestation is typically between the ages of 50 and 60 years
• Both men and women are affected, although a greater number of cases are reported in women
• The condition affects all races and ethnic groups. Fair-skinned Caucasians have a generally higher prevalence rate, while dark-skinned individuals are affected to a much lesser extent

What are the Risk Factors for Palmoplantar Psoriasis? (Predisposing Factors)

The following are the risk factors for Palmoplantar Psoriasis:

• Palmoplantar Psoriasis has a strong association with genetic factors. Studies have shown a correlation between psoriasis and individuals with certain types of human leukocyte antigens (HLAs). HLAs are gene complexes that form a part of the immune system
• Certain studies have also demonstrated that individuals with close relatives already affected by the condition are at a higher risk for the disease in comparison to the rest of the population. Hence, having a family member with psoriasis is a significant risk factor
• Caucasians, who are fair-skinned, are more susceptible to psoriasis
• Individuals having other forms of psoriasis, such as psoriasis vulgaris, are at an elevated risk for Palmoplantar Psoriasis
• HIV-infected patients are at an increased risk for psoriasis
• Individuals who are smokers, alcoholics, obese, diabetic, or with heart disease are at an increased risk for developing severe forms of the condition
• The symptoms may get worse during cold season - during fall and winter

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Palmoplantar Psoriasis? (Etiology)

Palmoplantar Psoriasis develops from an abnormal proliferation of the skin cells, referred to as keratinocytes. The exact reason behind this development is unknown. Although it is believed to be influenced by certain genetic factors.

• There seems to be an association of the skin disorder with a dysfunctional immune system, which results in an abnormally rapid growth of skin cells
• It is believed that the condition may be affected by certain environmental factors such as colder temperatures
• Palmoplantar Psoriasis can be triggered by certain external factors such as trauma to the skin, infection, or even contact dermatitis (hand dermatitis)

What are the Signs and Symptoms of Palmoplantar Psoriasis?

The signs and symptoms of Palmoplantar Psoriasis can vary in type and severity from one individual to another. In some, the symptoms may be mild and involve only a small localized area of the hands and feet; while in others, it can be severe and widespread, involving most of the palms and soles.

The signs and symptoms of Palmoplantar Psoriasis are known to periodically “appear and disappear”. A recurrent pattern, often lasting several years, may be noted.

• The affected areas of the palms and soles may present a burning sensation
• The individual often experiences itchiness and stinging sensation, causing the development of yellow patches
• Two types of skin patterns are seen:
  • Well-demarcated red patches that are scaly and forming at several locations
  • Skin thickening and scale formation that involve the entire palms of the hands and/or soles of the feet; the prominent redness associated with the condition is usually absent
• The patches develop tiny pustules that are 2-5 mm in diameter that tend to coalesce and form larger dark red scabby patches
• The crusts then develop fissures and painful cracks
• The patches that are localized to the palms and soles are usually symmetrical in presentation; i.e., both palms/soles show similar pattern

Psoriatic arthritis, affecting the hand, ankle, or knee joints with joint pain and inflammation, occurs in many individuals with Palmoplantar Psoriasis.

How is Palmoplantar Psoriasis Diagnosed?

Palmoplantar Psoriasis may present features that are similar to other skin conditions, such as tinea pedis, contact dermatitis involving the hands/feet, or acquired keratoderma, and so it may be difficult to diagnose Palmoplantar Psoriasis on the basis of a thorough physical examination, in some individuals unless other forms of psoriasis are also present.

A diagnosis of Palmoplantar Psoriasis would involve the following tests and exams:

• Complete physical examination and comprehensive medical history (including evaluation of family history of the condition)
• Dermoscopy: It is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
• Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation
• X-rays, CT, and MRI scan of the affected joint can help reveal the extent of damage due to inflammation in individuals with psoriatic arthritis
• Culture of skin scrapings may help in ruling out bacterial or fungal infections
• Skin biopsy: A skin tissue biopsy of the lesions may be performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed), and microscope findings, the pathologist arrives at a definitive diagnosis

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Palmoplantar Psoriasis?

Palmoplantar Psoriasis can cause a variety of complications depending on the severity of the disease activity. Some of these include:

• Severe pain, itchiness, and cracking of skin can lead to acute discomfort and irritation
• The lesions may occasionally develop bacterial or fungal infections
• The quality of life (performing simple tasks, walking, wearing footwear, etc.) may be affected by severe lesions involving the palms and soles
• Nail dystrophy is known to be associated with Palmoplantar Psoriasis
• Psychological issues such as social anxiety, stress, low self-esteem, depression, and often social isolation
• Due to its chronic nature, some individuals may undergo severe emotional issues and psychological distress that may require counseling
• Medication side effects that may be severe in some; medications, such as TNF-alpha inhibitors, may even trigger the condition

How is Palmoplantar Psoriasis Treated?

Palmoplantar Psoriasis is incurable with currently available treatment measures, although the extent of the disease and disease activity can be controlled with suitable medications. The goal behind the treatment is to help control the symptoms, prevent skin infections, and avoid long-term complications.

In general, the following medication/treatment methods are used to manage Palmoplantar Psoriasis:

• Mild conditions are treated topically by using recommended lotions, creams, and shampoos, or using potent topical corticosteroid ointments and creams, to help reduce or control the associated symptoms
  • Keeping the skin well-moisturized using suitable emollients (thick, greasy creams) helps prevent dryness and cracking
  • Application of coal tar to reduce skin inflammation
  • Thick, scaly skin may be improved using keratolytic agents (salicylic acid or urea)
  • Some topical steroid applications through prolonged use may aggravate the skin condition by thinning the skin
• For moderate to severe conditions, the following may be considered:
  • Oral medications such as acitretin and apremilast
  • Immunosuppressive drugs such as methotrexate and cyclosporin
  • Phototherapy (PUVA)
  • Biological therapy: This includes medications that are TNF-alpha inhibitors, Interleukin 12/23 inhibitors, and Interleukin 17 inhibitors
  • Janus kinase (JAK) inhibitor tofacitinib

Maintenance of overall health, certain lifestyle changes, and self-care measures can help reduce the severity of Palmoplantar Psoriasis, and these include:

• Healthy diet and regular exercises
• Obese and overweight individuals should consider an appropriate weight loss regimen
• Strict avoidance of tobacco and alcohol
• Undertaking treatment of any other health conditions

Medications can have significant side effects. Besides, since the medications are often needed for a long duration of time, it is recommended that combinations of medications be used to reduce side effects. This is known as rotational therapy.

How can Palmoplantar Psoriasis be Prevented?

Currently, there are no preventative measures available for Palmoplantar Psoriasis since it is a genetic condition. Ensuring proper self-care and regular healthcare visits are helpful in mitigating the severity and discomfort.

• Avoiding scratching the skin (or applying too much pressure on the skin) can help avoid aggravation of the skin lesions
• Avoid exposure to cold temperatures for prolonged periods
• Avoid triggers to the condition such as smoking, drinking alcohol, and weight gain
• Genetic testing of the expecting parents (and related family members) and prenatal diagnosis (molecular testing of the fetus during pregnancy) may help in understanding the risks better during pregnancy
• If there is a family history of the condition, then genetic counseling will help assess risks before planning for a child

Active research is currently being performed to explore the possibilities for treatment and prevention of inherited and acquired genetic conditions.

What is the Prognosis of Palmoplantar Psoriasis? (Outcomes/Resolutions)

• The prognosis for Palmoplantar Psoriasis depends on the extent of the condition and severity of signs and symptoms. It is generally good to excellent for mild cases
• In severe cases, the prognosis depends on the set of signs and symptoms. Severe disease can significantly affect one’s quality of overall life and result in long-term stress and depression since Palmoplantar Psoriasis symptoms may frequently recur and persist for years
• Since the skin condition lasts a lifetime, close monitoring of the symptoms with appropriate treatment will help decrease the burden of the disease

Additional and Relevant Useful Information for Palmoplantar Psoriasis:

• There is no evidence to prove that oily foods and chocolate-based products have an influence on the development of this condition
• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken to avoid strong soaps and chemicals that could potentially worsen the condition
• The presence of dirt on the body is not a causative factor for the condition. However, it helps to be clean and hygienic, which may help prevent the condition from getting worse