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Skin differentials – Pompholyx eczema vs palmoplantar pustulosis

The second in GP and hospital practitioner Dr Andy Jordan's series on differentiating two often similar-looking skin conditions

Both pompholyx eczema and palmoplantar pustulosis can cause an acute vesico-pustular eruption on hands and feet. But it is important to differentiate them because there are different therapeutic options, both topical and systemic.

Pompholyx eczema


• Can develop at any age

• Can occur in either sex

• An attack is characterised by a sudden onset of crops of clear vesicles which are deep and look like sago grains – with no erythema

• Sensation of heat and prickling precedes attacks

• Vesicles may become confluent and present as large bullae, especially on feet

• Severe itching can occur and attack resolves with desquamation in two to three weeks

• In mild cases, sides of fingers may be affected but typically symmetrical involvement of palms or soles occurs

• Recurrences usual

• More common in warm weather.


• Emollients

• Topical steroids

• Very occasionally, for severe attacks, a short course of oral steroids may be necessary.

Palmoplantar pustulosis

• Disease of adults, usually in middle age

• Marked preponderance in women

• May be a positive family history of psoriasis, though now thought to be a distinct entity from psoriasis

• Presents with well-defined plaques on thenar/hypothenar eminence/palm, and on instep or medial or lateral border of foot – sometimes the heel. Digital lesions are uncommon

• Usually strikingly symmetrical

• Area is dusty, red and often scaly. Numerous pustules, 2-5mm in diameter are present within this area at various stages of evolution, the freshest being yellow, then green, with the oldest pustules usually dark brown

• Usually causes a burning discomfort but can be slightly itchy

• Chronic, with spontaneous remissions unusual – often only temporary

• Associations are: thyroid disease, psoriasis at other sites, cigarette smoking at onset (although stopping smoking does not cause remission) and various arthropathies: sternoclavicular and manubrio-sternal arthritis.


• Superpotent topical steroids – with or without occlusion – help in short term, but condition flares after stopping

• Oral retinoids (Acitretin)


• Ciclosporin

• Lymecycline.

Dr Andy Jordan is a GP and hospital practitioner in dermatology in Chesham, Buckinghamshire

palmoplantar pustulosis