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.
Treatment
• 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.
Treatment
• Superpotent topical steroids – with or without occlusion – help in short term, but condition flares after stopping
• Oral retinoids (Acitretin)
• PUVA
• Ciclosporin
• Lymecycline.
Dr Andy Jordan is a GP and hospital practitioner in dermatology in Chesham, Buckinghamshire
palmoplantar pustulosis
