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Basics ⬇

Clinical Manifestations ⬆

There are two variants:

Hyperkeratotic !!navigator!!

  • Similar to its counterparts elsewhere, this form of psoriasis is characterized by well-demarcated, scaly plaques (Figs. 14.20 and 14.21).

  • Hyperkeratotic psoriatic plaques on the palms and soles may present additional problems such as pain, impairment of function, fissuring, bleeding, and social embarrassment.

Pustular !!navigator!!

  • This rare form of psoriasis is most commonly seen in adults and historically, has had many clinical descriptions and eponyms (i.e., pustulosis of the palms and soles and palmoplantar pustulosis).

  • Lesions present as small pinpoint pustules admixed with yellow-brown macules and papules or scaly erythematous plaques and tends to be bilaterally symmetric.

  • It favors the insteps of the feet, the heels, and the palms, and the thenar and hypothenar eminences of the hands (Figs. 14.22 and 14.23).

Diagnosis-icon.jpg Differential Diagnosis

Contact Dermatitis

  • Suspected, particularly if the eruption is on the dorsum of the hands or feet.

  • The patient has a history of exposure to a suspected contactant.

Hand Eczema or Dyshidrotic Eczema

  • “Sago-grain” vesicles may be present.

  • Pruritus.

  • The patient may have evidence of eczema elsewhere on the body or a personal or family history of atopy.

  • May be indistinguishable from palmoplantar psoriasis.

Tinea Manuum and Pedis

  • A “two-feet, one-hand” presentation is noted.

  • The KOH examination or fungal culture is positive.

Management-icon.jpg Management

  • Topical treatment is the first line of therapy.

  • Because of their thick stratum corneum, the palms and soles present the greatest barrier to cutaneous penetration; consequently, potent topical steroids are used, often under occlusion.

Options include the following:

  • Superpotent (class 1) topical steroids, such as clobetasol propionate, are first prescribed without occlusion, but occlusion (under vinyl or rubber gloves) may be used if necessary

  • Salicylic acid preparations such as Keralyt gel or Salex cream or lotion can be used to remove scale, if necessary

  • Calcipotriene (Dovonex) cream or Vectical ointment

When a patient is not responding to topical therapies, treatment options can include the following:

  • PUVA (see earlier discussion): topical PUVA therapy using a “hand-foot box”

  • Oral retinoids, such as Soriatane (etretinate) are often quite effective

  • The excimer laser, if available, is also highly effective

  • RePUVA (low-dose etretinate combined with PUVA)

  • Oral methotrexate

  • Oral cyclosporine

  • Biologics (see earlier discussion)

Outline