Palm and plantar psoriasis.

Among psoriatic rashes, which differ in the place of occurrence, dermatologists distinguish palmoplantar psoriasis.

With this localization of the disease, the skin areas of the distal parts of the upper limbs (palms) and lower limbs (soles of the feet) are affected. These are precisely the places where the outer horny layer of the epidermis is the thickest and contains the maximum number of layers of dead cells (corneocytes) - to strengthen the barrier function of the skin and provide additional protection from injury and abrasion.

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Epidemiology

Vulgar psoriasis is the most common form of this disease, affecting 80 to 90% of patients with psoriasis. And in approximately two-thirds of cases, palmoplantar psoriasis is associated with classic plaque psoriasis. At the same time, this localization of the pathology can be the beginning of generalized psoriasis in every fourth case out of ten.

The development of pustular palmoplantar psoriasis is more often observed in women aged 40 to 60 years.

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Causes palm and plantar psoriasis.

The key causes of palmoplantar psoriasis – a chronic recurrent skin pathology of autoimmune etiology – are the same as other varieties, see the detailed article – Causes of psoriasis. The disease is genetically determined and is transmitted through generations, although it rarely affects children. But what leads to its localization on the palms and soles is still unknown.

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Risk factors

Dermatologists associate the main risk factors for the development of palmar-plantar psoriasis with:

• with skin injuries and infections;
• with other autoimmune diseases such as type 2 diabetes, hyper or hypothyroidism, celiac disease (gluten intolerance);
• with stress and other conditions that destabilize the psyche and the functioning of the central nervous system;
• with obesity and metabolic syndrome;
• with hypocalcemia (calcium deficiency in the body);
• with smoking (in 95% of cases) and alcohol abuse;
• with streptococcal lesions of the pharyngeal and palatine tonsils;
• with the use of certain medications, in particular lithium and its derivatives, ACE inhibitors, beta-blockers, hormonal agents with progesterone, etc.

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Pathogenesis

The pathogenesis of accelerated proliferation of keratinocytes up to two or three days and their transformation into corneocytes in palmoplantar psoriasis is also based on characteristic disturbances of processes in the epidermis and dermis, which are a response to cytokines of immune cells. In this case, there is a thickening of the stratum corneum (hyperkeratosis) and the entire epidermis (acanthosis); the granular epidermal layer decreases; the expression of the ICAM1 gene increases, which codes for the surface glycoprotein CD54, which ensures intercellular adhesion in the epidermis.

Among the histopathological signs of psoriasis, specialists highlight the infiltration of neutrophils and activated lymphocytes from the dermis into the epidermis, as well as the presence of neutrophils in the stratum corneum of the epidermis and monocytes (mononuclear leukocytes) in the papillary layer of the dermis.

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Symptoms palm and plantar psoriasis.

The clinical symptoms of palmoplantar psoriasis depend on its type. In dermatology, the following types of psoriasis of this localization are distinguished:

• vulgaris or plaque palmoplantar psoriasis;
• pustular palmoplantar psoriasis (chronic pustular psoriasis of Barber or pustular palmoplantar psoriasis), which can be combined with plaque psoriasis.

In cases of plaque psoriasis on the palms and soles of the feet, the first signs appear as well-defined round erythematous macules (flat and <1 cm) or papules.

Stages

The progressive stage of the disease is characterized by their enlargement along the periphery and fusion with the formation of keratin plaques (from one to several centimeters in diameter), which take the form of calluses, but only covered with gray or silvery-white scales (as in ordinary psoriasis). When the upper layer of plaques desquamates, blood may appear. The skin loses moisture, the rashes become rough, leading to painful cracks.

At the stationary stage, new rashes stop, and existing plaques become pale and flattened, but exfoliation increases significantly. Read more - Stages of psoriasis

Chronic pustular palmoplantar psoriasis is manifested by the formation of hyperemic areas of the skin (as an initial sign), followed by the appearance in the upper part of the spinous and granular layers of the epidermis of spongiform (spongy) intercellular Kogoj pustules with a diameter of up to 0.5 cm. These are cavities with several "compartments" containing a mixture of keratinocytes and dead microphages-neutrophils (granulocyte leukocytes). Typical places for the appearance of pustules on the palms are near the base of the thumb, on the elevation in the area of the little finger, in the folds of the interphalangeal joints of the fingers; on the soles of the feet - in the areas of the arch of the foot and heel. When the pustules dry up (after about three weeks), dense dark brown crusts form in their place, which peel and itch. After this, the disease goes into a state of temporary remission.

Some sources note that with pustular psoriasis, raised pustules filled with pus appear above the reddened areas of the skin. This is defined as palmoplantar pustulosis, a chronic inflammatory skin disease. According to some dermatologists, this may be a type of psoriasis. But there is another point of view, confirmed by genetic studies and the establishment of a connection between palmoplantar pustulosis and neuroendocrine dysfunction of the sweat glands on the palms and soles of the feet.

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Complications and consequences

Consequences and complications of palmoplantar psoriasis: pain and difficulty walking, difficulty performing manual work (loss of ability to work is not excluded). A common complication is the addition of an infection.

Complete or subtotal involvement of the skin in psoriasis vulgaris can ultimately lead to erythroderma, which reduces the thermoregulatory functions of the skin and also causes metabolic disorders.

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Diagnostics palm and plantar psoriasis.

Diagnosis of palmoplantar psoriasis is usually based on the appearance of the affected area. There is no need to do any special blood tests.

However, since the clinical picture of palmoplantar psoriasis resembles eczema and fungal diseases (mycoses), a mycological scraping from the plaque or a skin biopsy may be required to establish an accurate diagnosis.

Instrumental diagnostics may include dermatoscopy, i.e. examination of the skin with multiple magnification and scanning of rashes - with recording of their images, which allows for objective monitoring of the development of pathology.

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Differential diagnosis

Differential diagnosis should consider the possibility of the presence of other papulosquamous dermatological diseases in patients, including: tinea pedis, lichen planus, pink lichen, herpes zoster, keratoderma blennorrhagicum of the palms and soles, hyperkeratotic eczema, subcorneal pustular dermatosis (Sneddon-Wilkinson syndrome), acute exanthematous pustulosis, impetigo herpetiformis, acrodermatitis, etc.

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Treatment palm and plantar psoriasis.

The main local treatments for palmoplantar psoriasis are:

• Corticosteroid ointments, in this case the greatest effect is given by ointments and creams for psoriasis containing a powerful GCS clobetasol propionate (Clobetasol, Dermovate, Clovate, PsoriDerm). Clobetasol can be used twice a day (and under a bandage), but not more than five days in a row (to avoid thinning of the skin and possible systemic side effects.
• Coal tar derivatives - Anthralin ointment (Antraderm, Psoriaten, Dithranol, Tsignoderm), which is used in the stationary stage of the disease, applying to the affected areas of the skin for 30-40 minutes once a day (for two months).
• Emollients, moisturizers, keratolytic external agents (urea, 2% salicylic acid, etc.). More details in the publication - Non-hormonal ointments for psoriasis

But the ointment Psorkutan (other trade name Daivonex) based on hydroxyvitamin D3 (calcipotriol), as clinical practice shows, is not very effective for psoriasis of the palms and soles.

In more severe forms of pustular palmoplantar psoriasis, physical therapy in the form of PUVA therapy is required, as well as drugs for systemic use: retinoids Acitretin (Neotigason), Isotretinoin (Accutane, Acnecutane, Verocutane, Roaccutane, Sotret), Etretinate (Tigason); tumor necrosis factor alpha (TNF-alpha) inhibitors Infliximab or Adalimumab.

Synthetic analogues of retinoic acid – Isotretinoin, Etretinate and Acitretin – help to normalize the division of skin keratinocytes. Isotretinoin, Acitetine or Etretinate capsules are taken orally during meals at a daily dose of 0.1 mg per kilogram of the patient's body weight. The maximum daily dose is 25-30 mg. Treatment can last two to three months with a two-month break before a repeat course. Possible side effects of systemic retinoids include reactions to increased intake of vitamin A in the body: dry and itchy skin, cheilitis, alopecia, deposition of calcifications in tissues, increased lipid levels in the blood.

The drug Infliximab is administered intravenously during hospital treatment, the dose is determined individually at the rate of 3-5 mg per kilogram of body weight. This drug has a long list of undesirable side effects, including: skin rashes (including bullous), increased dryness, hyperkeratosis, hair loss; fever; shortness of breath and bronchitis; nausea, diarrhea, abdominal pain; headaches, dizziness, increased fatigue; pain in the chest area, instability of blood pressure and heart rate; decreased blood clotting.

For more information see – Psoriasis Treatment

In drug therapy of plaque palmoplantar psoriasis, homeopathy can be used - homeopathic ointments Psorilom (with milk thistle seed oil and extracts of medicinal plants) and Psoriaten (based on the extract of the bark of Mahonia aquifolium). These products are used twice a day.

Folk remedies

Folk remedies offer various remedies that can help reduce the severity of palmoplantar psoriasis symptoms.

It is recommended to take omega-3 fatty acids orally, for which flaxseed oil (a dessert spoon per day), crushed flax seed (20 mg) or fish oil (one capsule per day) are used.

Baths for feet and hands with decoctions of chamomile, St. John's wort, licorice (licorice root), birch buds are useful. And also herbal teas, which include calendula flowers, bogbean or dandelion leaves, sweet clover herb - mixed with green tea - 100 ml three times a day.

Among the folk recipes are infusions of fireweed (fireweed) - a tablespoon of dry raw material per 200 ml of boiling water; infusion of oregano, black elder flowers, three-part succession, stinging nettle, prickly restharrow, wild pansy, mullein. If you are interested in how to carry out herbal treatment, read the details in the article - Medicinal herbs for psoriasis

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Prevention

Is it possible to prevent palmoplantar psoriasis? Read – Psoriasis Prevention

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Forecast

The prognosis for this disease is poor, as it is very treatable.

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