Clinical presentation of a patient with palmoplantar pustular psoriasis: a case report
Vedrana Bulat1, Iva Borovečki1, Mirna Šitum1, Iva Dediol1, Ivana Pavić2, Ivana
1Department of Dermatology and Venereology, University Hospital Center «Sestre
milosrdnice», Vinogradska cesta 29, Zagreb, Croatia
2Ljudevit Jurak Universitiy Department of Pathology, Sestre Milosrdnice University
Hospital Center, Vinogradska cesta 29, Zagreb, Croatia
Background: Palmoplantar pustular psoriasis is a rare, chronic dermatosis
characterized by sterile pustules that develop within areas of erythema and scaling
on the palms, soles or both. The minority of patients have chronic plaque psoriasis
Focal infections and stress have been reported as triggering factors. Smoking aggra-
vates the disease and negatively reflects on treatment success. The disorder occurs
more commonly during the fourth decade of life. There is a slight female predilection.
In most patients lesions are asymptomatic; however, intermittent pruritus, and burn-
ing have been described. The histologic hallmark of palmoplantar pustular psoriasis
is a large accumulation of neutrophils within the stratum spinosum known as spongi-
form pustule of Kogoj.
Palmoplantar pustular psoriasis must be differentiated from other dermatoses which
are characterized by intraepidermal neutrophilic pustules including impetigo, superfi-
cial candidiasis, dermatophyte infection, superficial folliculitis, dyshidrotic eczema,
and pustular drug eruption. Therefore, biopsy and histological analysis is recommen-
ded in order to confirm the diagnosis.
Objective: The aim of this case report was to present our patient suffering from pal-
moplantar pustular psoriasis, and to evaluate clinical presentation, diagnostic and
therapeutic difficulties in this rare condition.
Case report: A 38-year-old female patient was admitted to our Hospital due to numer-
ous sterile pustules sited on well-defined erythematous plaques with desquamation
on the palms and soles three months ago. The pustules were large (up to 5mm in
diameter), and several stages of evolution of pustules were present concurrently (Fig-
ure 1, 2). Patient complained because of occasional pruritus and burning. Chronic
plaque psoriasis on elbows was confirmed seven years ago for which she received
Focal infections were not found during clinical examination. It is important to note that
patient’s smoking habit aggravates the condition.
Palmoplantar pustular psoriasis has been diagnosed based on the clinical picture and
pathohistological appearance. Pathohistological analysis of skin lesion of the sole
has shown epidermal acanthosis with parakeratosis and large accumulation of neut-
rophils within the stratum spinosum known as spongiform pustule of Kogoj (Figure 3,
4). In the dermis, the capillaries were elongated and tortuous. PUVA cream photo-
therapy was administered five times weekly during four weeks of hospitalization. Top-
ical corticosteroids were applied under hydrocolloid occlusion which significantly en-
hanced the regression of skin lesions.
Conclusion: Most patients with palmoplantar pustular psoriasis have an underlying
disease that can be identified, but in our case the onset, fluctuations and duration of
disease were not associated with focal infections. It is important to stress the fact that
smoking aggravates the disease and negatively reflects on treatment success.
PUVA cream phototherapy and topical corticosteroids have provided a dramatic im-
provement of disease with significant psychosocial benefit.
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Figure 1. Multiple pustules on the sole.
Figure 2. Multiple pustules up to 5 mm.
Figure 3. Large accumulation of neutrophils within stratum spinosum (HEx40).
Figure 4. Different area of the same sample (HEx200).