Conference Paper

Clinical presentation of a patient with palmoplantar pustular psoriasis: a case report

Conference: 22nd Ljudevit Jurak International Symposium on Comparative Pathology, Zagreb 2011

ABSTRACT 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 elsewhere.
Focal infections and stress have been reported as triggering factors. Smoking aggravates 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 burning have been described. The histologic hallmark of palmoplantar pustular psoriasis is a large accumulation of neutrophils within the stratum spinosum known as spongiform pustule of Kogoj.
Palmoplantar pustular psoriasis must be differentiated from other dermatoses which are characterized by intraepidermal neutrophilic pustules including impetigo, superficial candidiasis, dermatophyte infection, superficial folliculitis, dyshidrotic eczema, and pustular drug eruption. Therefore, biopsy and histological analysis is recommended in order to confirm the diagnosis.
Objective: The aim of this case report was to present our patient suffering from palmoplantar 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 numerous 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 (Figure 1, 2). Patient complained because of occasional pruritus and burning. Chronic plaque psoriasis on elbows was confirmed seven years ago for which she received topical corticosteroids.
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 neutrophils within the stratum spinosum known as spongiform pustule of Kogoj (Figure 3, 4). In the dermis, the capillaries were elongated and tortuous. PUVA cream phototherapy was administered five times weekly during four weeks of hospitalization. Topical corticosteroids were applied under hydrocolloid occlusion which significantly enhanced 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 improvement of disease with significant psychosocial benefit.

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