Psoriasis of the palms and soles

Psoriasis may predominantly affect the palms and soles in various ways:

• Typical scaly, red patches similar to psoriasis elsewhere
• Generalised thickening and scaling of the palms and soles (keratoderma)
• Sheets of tiny yellow-brown pustules (palmoplantar pustulosis).

Palmoplantar psoriasis

More images of palmoplantar psoriasis ...

Clinical features

The palms and soles can become very dry and thickened, often with deep painful cracks (fissures), which can significantly interfere with activities.

Psoriasis can be quite hard to differentiate from other forms of keratoderma, particularly hand dermatitis, but signs of psoriasis elsewhere may help make a diagnosis.

Palmoplantar psoriasis tends to be a chronic recurrent condition. The pustular form is reported to be much more common in tobacco smokers, but unfortunately giving up smoking doesn't always result in clearance of the psoriasis.

Treatment

Mild psoriasis of the palms and soles may be treated with topical treatments:

• Emollients: thick, greasy barrier creams applied thinly and frequently to moisturise the dry, scaly skin and help prevent painful cracking.
• Coal tar: to improve the scale and inflammation. Because of the mess, often applied at night under cotton gloves.
• Keratolytic agents such as urea or salicylic acid to thin down thick scaling skin
• Topical steroids: ultrapotent ointment applied initially daily for two to four weeks, if necessary under occlusion, to reduce inflammation, itch and scaling. Maintenance use only at weekends to avoid thinning the skin and causing the psoriasis to become more extensive.

Calcipotriol ointment is not very successful and may cause an irritant dermatitis on the face if a treated area inadvertently touches it. Dithranol is too messy for routine use on hands and feet.

More severe disease usually requires phototherapy or systemic agents:

• PUVA
• Acitretin

Methotrexate