From the Guidelines
Acrodermatitis Continua of Hallopeau is a rare and disabling condition that can result in considerable morbidity due to intense pustular inflammation centered around the terminal phalanges, often leading to destruction of the nail plate and associated with a destructive arthritis of adjacent joints.
Definition and Characteristics
Acrodermatitis Continua of Hallopeau is characterized by sterile pustules that primarily affect the fingertips and toes, considered a variant of pustular psoriasis targeting the distal portions of fingers and toes, often beginning around the nail bed. The condition typically starts with painful, red, inflamed skin that develops pustules, which then evolve into scaling and crusting. Over time, it can cause severe nail damage, leading to nail dystrophy or complete nail loss. The skin underneath may become thickened, and the affected digits can develop painful fissures.
Treatment Options
Treatment options for Acrodermatitis Continua of Hallopeau include:
- Topical corticosteroids
- Vitamin D analogs like calcipotriol
- Calcineurin inhibitors as first-line therapies
- For more severe cases, systemic treatments such as methotrexate, cyclosporine, acitretin, or biologics (TNF inhibitors, IL-17 inhibitors, or IL-23 inhibitors) may be necessary, as suggested by 1
- TNF antagonists (etanercept, infliximab, and adalimumab) have shown significant benefit in at least 10 case reports for this rare but disabling condition, making them a reasonable recommendation for patients with a major impact on quality of life, as noted in 1
Challenges and Considerations
The condition is particularly challenging to treat and often requires combination therapy or rotation between different treatment modalities. The exact cause remains unknown, but genetic factors and immune system dysfunction are believed to play significant roles in its development. Given the potential for severe morbidity and impact on quality of life, aggressive treatment approaches, including biologics, should be considered early in the management of Acrodermatitis Continua of Hallopeau, especially in cases where conventional therapies fail to provide adequate relief, as indicated by the guidelines and evidence from 1.
From the Research
Definition and Characteristics
- Acrodermatitis Continua of Hallopeau (ACH) is a rare chronic inflammatory skin disease [ 2 ].
- It is considered a localized form of pustular psoriasis [ 3 ].
- ACH is characterized by sterile pustules, paronychia, and atrophic skin changes, onychodystrophy, and osteolysis of the distal phalanges of the fingers and toes [ 4 ].
Clinical Presentation and Progression
- The condition presents with tender pustules and underlying erythema on the tip of a digit, more frequently arising on a finger than a toe [ 3 ].
- The natural progression of ACH is chronic and progressive, often resulting in irreversible complications such as onychodystrophy, anonychia, and osteitis [ 3 ].
Treatment Options
- Treatment is extremely challenging and mostly based on empirics due to scarce evidence from case reports and few small case series [ 2 ].
- Systemic treatments, including methotrexate, acitretin, and biologics such as guselkumab, secukinumab, and adalimumab, have been used with varying degrees of success [ 2 ].
- Biologics, particularly anti-tumor necrosis factor agents and IL-17 inhibitors, have shown promise in treating ACH [ 3 , 4 , 5 ].
- Combination therapy with ustekinumab and acitretin has also been reported to be effective in some cases [ 6 ].