Description

A 63-year-old woman presented with multiple painful pustular lesions over both her feet. The patient reported that the lesions used to exacerbate every 1 week in a month for the last 10 years. She claimed to receive several courses of unsuccessful treatment attempts including various medication and off-label drugs. On examination, she had multiple erythematous pustular lesions of 2–7 mm in diameter over the plantar surfaces of her feet (figure 1). Additionally, similar lesions overlying a desquamated skin were evident on the palmar aspect of her hands (figure 2). Histopathological examination revealed hyperkeratosis with orthoheratosis, acanthosis, spongiosis and papillomatosis. A subgranular pustule, filled with polymorph nuclear neutrophils, was also observed within the epidermis. A diagnosis of pustulosis palmaris et plantaris (PPP) was made. The differential diagnosis of this rare entity should include acute generalised exanthematous pustulosis, acrodermatitis continua, infected eczema, pompholyx and tinea pedis et manuum. Treatment is extremely challenging. Although several topical and systemic agents such as corticosteroids, retinoids, clochicine, methotrexate, ciclosporin and photochemotherapy have been reported to be used with varying efficacies,1 there is still no established guideline for the management of the disease. Smoking has been postulated to up-regulate the reactivity to PPP, possibly by inducing exposure of more antigens or by changing the surface properties of the acrosyringium (the eccrine sweat duct in the epidermis and stratum corneum), hence cessation of smoking may provide partial relief in some patients.2

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Figure 1

Multiple erythematous pustular lesions of 2–7 mm in diameter over the plantar surfaces of the feet.

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Figure 2

Erythematous pustular lesions overlying the desquamated skin of the palmar aspect of both hands.