What is the treatment for palmoplantar pustules?

Treatment for Palmoplantar Pustulosis

The combination of oral PUVA with oral retinoids should be considered as the first-line treatment for palmoplantar pustulosis, unless there are contraindications. 1

First-Line Treatment Options

Phototherapy + Retinoid Combination

• Oral PUVA + Oral Retinoids: This combination has shown superior efficacy compared to either treatment alone
  • Clearance rates of 61-100% with combination therapy versus 21-44% with PUVA alone 1
  • Strength of recommendation: A; level of evidence: 1+ 1
  • Acitretin is the most commonly used retinoid for this purpose

Monotherapy Options (if combination therapy is contraindicated)

1. Oral PUVA:

   • Demonstrated effectiveness as monotherapy with clearance rates of 21-55% 1
   • Strength of recommendation: C; level of evidence: 2++ 1
   • Common side effects include erythema, pruritus, and nausea 1

2. Oral Retinoids:

   • Acitretin is particularly effective for pustular forms of psoriasis 1
   • Clearance rates of 17-70% reported in studies 1
   • Particularly valuable in hyperkeratotic palmoplantar psoriasis 1

Second-Line Treatment Options

Topical Treatments

• Potent Topical Corticosteroids:

  • Can be used for milder cases or as adjunctive therapy
  • Hydrocolloid occlusive dressing plus triamcinolone acetonide cream has shown superior efficacy to clobetasol cream alone 2
  • Complete clearance in 63% of patients with hydrocolloid dressing plus triamcinolone versus 21% with clobetasol alone 2

• Topical Vitamin D Derivatives:

  • Maxacalcitol may be more effective than placebo in achieving clearance 3
  • Low risk of adverse effects 3

Biologics (for refractory cases)

• IL-17 Inhibitors (Secukinumab):

  • Probably superior to placebo in reducing disease severity 3
  • Consider for patients who fail conventional therapies

• IL-23 Inhibitors (Guselkumab):

  • Probably effective in reducing disease severity 3
  • Moderate-quality evidence supports its use 3

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of pustules, erythema, and scaling
   • Check for contraindications to retinoids (pregnancy, liver disease) or PUVA (photosensitivity disorders, skin cancer)

2. Treatment Selection:

   • Mild disease: Start with potent topical corticosteroids, possibly under occlusion
   • Moderate-to-severe disease: Proceed to combination therapy of oral PUVA with oral retinoids

3. Treatment Protocol for PUVA + Retinoid:

   • Begin with 2 weeks of retinoid monotherapy (acitretin)
   • Add PUVA therapy after initial retinoid treatment
   • Initial UVB dose should be decreased by 30-50% for the first week due to increased photosensitivity from retinoids 1

4. For Refractory Cases:

   • Consider biologics (secukinumab, guselkumab)
   • Emerging evidence supports JAK inhibitors like tofacitinib 4

Important Considerations and Pitfalls

Monitoring

• Regular monitoring for adverse effects of retinoids (lipid abnormalities, liver function)
• Watch for PUVA-related side effects (erythema, nausea, photosensitivity)
• Long-term PUVA carries risk of skin cancer; limit cumulative exposure

Common Pitfalls

1. Inadequate treatment duration: Palmoplantar pustulosis is chronic and often requires prolonged management
2. Relying solely on topical therapy for moderate-to-severe disease
3. Discontinuing treatment too early after initial improvement
4. Not addressing potential triggers like smoking or upper respiratory infections 5

Special Populations

• Pregnancy: Avoid retinoids (teratogenic) and PUVA
• Patients with comorbid arthritis: Consider methotrexate or cyclosporine 6

Palmoplantar pustulosis remains challenging to treat, with frequent relapses. The combination of oral PUVA with oral retinoids offers the best evidence-based approach for most patients with moderate-to-severe disease, while topical therapies may suffice for milder cases.