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Heidemeyer K, May Lee M, Cazzaniga S, Yawalkar N, Naldi L. Palmoplantar Pustulosis: A Systematic Review of Risk Factors and Therapies. PSORIASIS (AUCKLAND, N.Z.) 2023; 13:33-58. [PMID: 37772169 PMCID: PMC10522454 DOI: 10.2147/ptt.s400402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/16/2023] [Indexed: 09/30/2023]
Abstract
Palmoplantar pustulosis (PPP) is a chronic, relapsing, inflammatory disease that can occur alone or in association with arthritis. There is still controversy about whether it should be separated from psoriasis or classified as pustular psoriasis. Furthermore, drug-induced paradoxical PPP is a special variant of PPP that differs from classic PPP in several ways. Treatment of PPP is still challenging, and there are a number of treatment-resistant cases. This review summarizes the risk factors for the development of PPP and the currently available treatment modalities. Female sex, smokers or ex-smokers, obesity, thyroid dysfunction, and treatment with a tumor necrosis factor (TNF)-α inhibitor have been identified as risk factors for the disease's development, severity, and course. Topical treatments and phototherapy are effective for some patients and are used as a first-line or adjuvant treatment modality. Conventional treatments including retinoids and fumaric acid show good effects and can increase the efficacy of treatment with psoralen + ultraviolet light therapy (PUVA). Ciclosporin is fast acting, but relapse mostly occurs immediately after cessation. TNF-α inhibitors are efficient, and an even better response can be achieved with IL-17 and IL-23 blockers as well as apremilast. The effect of Janus kinase inhibitors seems to be promising according to case reports, but further investigations with larger cohorts are needed.
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Affiliation(s)
- Kristine Heidemeyer
- Department of Dermatology, Inselspital University Hospital of Bern, Bern, Switzerland
- Centro Studi GISED, Bergamo, Italy
| | - Marco May Lee
- Section of Dermatology, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Simone Cazzaniga
- Department of Dermatology, Inselspital University Hospital of Bern, Bern, Switzerland
- Centro Studi GISED, Bergamo, Italy
| | - Nikhil Yawalkar
- Department of Dermatology, Inselspital University Hospital of Bern, Bern, Switzerland
| | - Luigi Naldi
- Centro Studi GISED, Bergamo, Italy
- Dermatology Department, S. Bortolo Hospital, Vicenza, Italy
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Xu JM, Wang HM, Jin HZ. An update on therapeutic options for palmoplantar pustulosis: a narrative review and expert recommendations. Expert Rev Clin Immunol 2023; 19:499-516. [PMID: 36970858 DOI: 10.1080/1744666x.2023.2185775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Palmoplantar pustulosis (PPP) is a chronic inflammatory skin disease belonging to the localized form of pustular psoriasis. It is characterized by sterile pustule formation in palms and soles and a recurrent disease course. Although we have many treatments for PPP, there is no authoritative guidance. AREAS COVERED A thorough search of PubMed was conducted to identify studies in PPP from 1973 onwards, with additional references to specific articles. Any treatment methods were outcomes of interest, including topical treatment, systemic treatment, biologics, other targeted treatments, phototherapy, and tonsillectomy. EXPERT OPINION Topical corticosteroids are suggested as first-line therapy. Oral acitretin has become the most applied systemic retinoid recommended in PPP without joint involvement. For patients with arthritis, immunosuppressants like cyclosporin A and methotrexate are more recommended. UVA1, NB-UVB, and 308-nm excimer laser are effective phototherapy options. The combinations of topical or systemic agents and phototherapy may enhance the efficacy, particularly in recalcitrant cases. Secukinumab, ustekinumab, and apremilast are the most investigated targeted therapies. However, heterogeneous reported outcomes in clinical trials provided low-to-moderate quality evidence of their efficacy. Future studies are required to address these evidence gaps. We suggest managing PPP based on the acute phase, maintenance phase, and comorbidities.
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Genovese G, Moltrasio C, Cassano N, Maronese CA, Vena GA, Marzano AV. Pustular Psoriasis: From Pathophysiology to Treatment. Biomedicines 2021; 9:biomedicines9121746. [PMID: 34944562 PMCID: PMC8698272 DOI: 10.3390/biomedicines9121746] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/21/2022] Open
Abstract
Pustular psoriasis (PP) is a clinicopathological entity encompassing different variants, i.e., acute generalized PP (GPP), PP of pregnancy (impetigo herpetiformis), annular (and circinate) PP, infantile/juvenile PP, palmoplantar PP/palmoplantar pustulosis, and acrodermatitis continua of Hallopeau (ACH), which have in common an eruption of superficial sterile pustules on an erythematous base. Unlike psoriasis vulgaris, in which a key role is played by the adaptive immune system and interleukin (IL)-17/IL-23 axis, PP seems to be characterized by an intense inflammatory response resulting from innate immunity hyperactivation, with prominent involvement of the IL-36 axis. Some nosological aspects of PP are still controversial and debated. Moreover, owing to the rarity and heterogeneity of PP forms, data on prognosis and therapeutic management are limited. Recent progresses in the identification of genetic mutations and immunological mechanisms have promoted a better understanding of PP pathogenesis and might have important consequences on diagnostic refinement and treatment. In this narrative review, current findings in the pathogenesis, classification, clinical features, and therapeutic management of PP are briefly discussed.
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Affiliation(s)
- Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.G.); (C.M.); (C.A.M.)
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.G.); (C.M.); (C.A.M.)
- Department of Medical Surgical and Health Sciences, University of Trieste, 34137 Trieste, Italy
| | - Nicoletta Cassano
- Dermatology and Venereology Private Practice, 76121 Barletta, Italy; (N.C.); (G.A.V.)
| | - Carlo Alberto Maronese
- Dermatology Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.G.); (C.M.); (C.A.M.)
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Gino Antonio Vena
- Dermatology and Venereology Private Practice, 76121 Barletta, Italy; (N.C.); (G.A.V.)
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.G.); (C.M.); (C.A.M.)
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
- Correspondence:
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Peng C, Hu Y, Chen W, Ding Y, Li X, Yu N, Lu J, Shi Y. A randomized prospective study of different dose regimens using the 308-nm excimer laser in the treatment of palmoplantar pustulosis. Dermatol Ther 2021; 34:e15079. [PMID: 34333826 DOI: 10.1111/dth.15079] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
The objective of this study was to evaluate optimal treatment regimen of 308-nm excimer laser for palmoplantar pustulosis (PPP). 77 patients with PPP were randomly assigned to receive low dose (2-fold of MED as initial dose), medium dose (4-fold of MED as initial dose) and high dose group (6-fold of MED as initial dose) and the MED of each patient depended on the ultraviolet light sensitivity of individual's skin which ranged from 0.1 to 0.25 J/cm2 . All group received 308-nm excimer laser treatment three times weekly for 8 weeks. Clinical evaluation based on the Palmoplantar Pustular Psoriasis Area and Severity Index (PP-PASI) and Dermatology Life Quality Index (DLQI) score. All treatment groups achieved satisfied efficacy at the end of the treatment period with more obvious reduction of PP-PASI score in high dose group (16.05 ± 4.26) than low and medium dose group (23.67 ± 7.16, p < 0.01; 22.04 ± 5.74, p < 0.01). Improvement of DLQI score was greatest at week 4 for all patients in each group, while DLQI improved more quickly in high/medium dose group than low dose group. Adverse effects of erythema, blistering and erosions were more common with the higher dose regimen. High dose of 308-nm excimer laser could achieve a better efficacy in PPP treatment, reduce the severity of the disease in patients and improve the life quality of patients. Meantime, the incidence of adverse reactions should be aware of and it's necessary to evaluate the skin and lesion type before the dose selection.
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Affiliation(s)
- Chen Peng
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
| | - Yifan Hu
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
| | - Wenjuan Chen
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
| | - Yangfeng Ding
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
| | - Xingzi Li
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
| | - Ning Yu
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
| | - Jiajing Lu
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
| | - Yuling Shi
- Department of Dermatology, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Institute of Psoriasis, School of Medicine, Tongji University, Shanghai, China
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Misiak-Galazka M, Zozula J, Rudnicka L. Palmoplantar Pustulosis: Recent Advances in Etiopathogenesis and Emerging Treatments. Am J Clin Dermatol 2020; 21:355-370. [PMID: 32008176 PMCID: PMC7275027 DOI: 10.1007/s40257-020-00503-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Palmoplantar pustulosis (PPP) is a chronic, recurrent skin disease belonging to the spectrum of psoriasis. It is characterized by an eruption of sterile pustules on the palms and soles. Recent studies in PPP have focused on genetic differences between pustular phenotypes and the role of the innate immunological system and the microbiome in the etiopathogenesis of the disease. Mutations in IL36RN (a major predisposing factor for generalized pustular psoriasis) were found in selected patients with PPP and were associated with earlier disease onset. Studies have shown that the interleukin (IL)-17 and IL-36 pathways might be involved in the pathogenesis of PPP. A microbiome has been demonstrated in the vesicopustules of PPP, and an abundance of Staphylococcus appears to be increased by smoking. Improved understanding of the underlying etiopathogenesis of PPP has led to advances in treatment options, and targeted therapies for PPP have been evaluated or are under evaluation against more than 12 molecules in ongoing clinical trials. These targets include CXCR2 (IL-8 receptor type B), granulocyte colony-stimulating factor receptor, IL-1 receptor, IL-8, IL-12, IL-23, IL-17A, IL-17 receptor, IL-36 receptor, phosphodiesterase-4, and tumor necrosis factor-α.
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Affiliation(s)
| | - Joanna Zozula
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008, Warsaw, Poland
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008, Warsaw, Poland.
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Barnard I, Eadie E, McMillan L, Moseley H, Brown T, Wood K, Dawe R. Could psoralen plus ultraviolet A1 (‘
PUVA
1’) work? Depth penetration achieved by phototherapy lamps. Br J Dermatol 2019; 182:813-814. [DOI: 10.1111/bjd.18561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- I.R.M. Barnard
- Scottish Universities Physics Alliance School of Physics and Astronomy University of St Andrews St Andrews U.K
| | - E. Eadie
- Photobiology Unit NHS Tayside Ninewells Hospital Dundee U.K
| | - L. McMillan
- Scottish Universities Physics Alliance School of Physics and Astronomy University of St Andrews St Andrews U.K
| | - H. Moseley
- Photobiology Unit NHS Tayside Ninewells Hospital Dundee U.K
| | - T. Brown
- Scottish Universities Physics Alliance School of Physics and Astronomy University of St Andrews St Andrews U.K
| | - K. Wood
- Scottish Universities Physics Alliance School of Physics and Astronomy University of St Andrews St Andrews U.K
| | - R. Dawe
- Photobiology Unit NHS Tayside Ninewells Hospital Dundee U.K
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Silpa-Archa N, Pattanaprichakul P, Charoenpipatsin N, Jansuwan N, Udompunthurak S, Chularojanamontri L, Wongpraparut C. The efficacy of UVA1 phototherapy in psoriasis: Clinical and histological aspects. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2019; 36:21-28. [PMID: 31309611 DOI: 10.1111/phpp.12498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/12/2019] [Accepted: 07/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although ultraviolet A1 (UVA1) phototherapy is available for nearly 30 years, only few studies have been conducted for plaque-type psoriasis. OBJECTIVES To determine the efficacy and safety of UVA1 phototherapy in psoriasis by assessing the clinical and histological outcomes. METHODS This open study enrolled 15 patients with moderate to severe plaque-type psoriasis. All of the patients had skin type IV. A whole-body UVA1 device consisting of 24 lamps, was irradiated at a medium dose of 50 J/cm2 three-times weekly for 30 sessions. Topical and systemic psoriasis treatments were discontinued before and during treatment; patients could only use emollients and antihistamines until 1-month post-completion. Psoriasis Area and Severity Index (PASI) scores were determined at baseline; at sessions 10th, 20th and 30th; and 1 month after treatment. Four-millimetre punch biopsies were obtained from the same psoriasis lesion at baseline and session 30th. Changes in histopathological gradings and polymorphonuclear, lymphocyte and Langerhans cell numbers were monitored. RESULTS Twelve patients completed the study. The mean age was 41.3 years (range: 25-71). The median PASI scores at baseline, session 30th and 1-month post-treatment were 16 (8.2, 43.3), 11 (4.4, 43.3) and 9.2 (2.7, 36.4), respectively. Although the PASI scores had improved significantly by 1-month post-treatment (P = .006), the histological parameters demonstrated minimal changes. All patients tolerated the phototherapy well and the most common side effect was skin tanning. CONCLUSIONS While medium-dose UVA1 phototherapy demonstrated some efficacy in moderate to severe plaque-type psoriasis. However, it might not be an excellent choice.
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Affiliation(s)
- Narumol Silpa-Archa
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Penvadee Pattanaprichakul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Norramon Charoenpipatsin
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natchaya Jansuwan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suthipol Udompunthurak
- Division of Clinical Epidemiology, Office of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanisada Wongpraparut
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Chia BKY, Chia GSZ, Tan EST, Tan VWD, Chong WS. Ultraviolet-A1 phototherapy in Asian skin: A review of 159 cases in Singapore. Indian J Dermatol Venereol Leprol 2019; 86:162-168. [PMID: 30829299 DOI: 10.4103/ijdvl.ijdvl_751_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Ultraviolet-A1 phototherapy has been used to treat many inflammatory dermatoses. Aims To determine the efficacy and safety of ultraviolet-A1 phototherapy in Asian skin. Materials and Methods We performed a review of records of patients undergoing ultraviolet-A1 phototherapy at our dermatology unit in Singapore from January 2007 to January 2011. Their electronic medical records were reviewed and a standardized questionnaire was filled up for data collection and tabulation. Chi-square or Fisher's exact tests were used to compare the difference in response between various groups for each characteristic. P value of < 0.05 was considered statistically significant. Results Our study comprised of 159 patients, of which 103 were patients with hand and foot eczema, 21 with atopic dermatitis, 17 with scleroderma and the remaining with miscellaneous dermatoses. Of these patients, 47.6% of patients with hand and feet eczema had good response after 10 sessions, which increased to 75% after 20 sessions and to 84.6% after 30 sessions. After 10 sessions, 47.6% of patients with atopic dermatitis had good response, which increased to 66.7% after 20 sessions. After 30 sessions, all the three remaining patients with atopic dermatitis experienced good response. For patients with scleroderma, only 11.8 and 10% had good response after 10 and 20 sessions, respectively, which increased to 40% after 30 sessions. Limitations Limitations of our study include its retrospective design and, consequently, the lack of standardized treatment protocol, as well as subjective assessment in terms of clinical improvement. Conclusions Ultraviolet-A1 phototherapy appears to be efficacious for the treatment of hand and foot eczema as well as atopic dermatitis. However, in patients with scleroderma, the response was partial and needed a longer duration of treatment.
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Affiliation(s)
| | - Gabriel S Z Chia
- Department of Occupational and Environmental Medicine, Singapore General Hospital, Singapore
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Howell ST, Cardwell LA, Feldman SR. A Review and Update of Phototherapy Treatment Options for Psoriasis. CURRENT DERMATOLOGY REPORTS 2018. [DOI: 10.1007/s13671-018-0211-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Su LN, Ren J, Cheng SM, Liu JL, Ding YF, Zhu NW. UVA1 vs. narrowband UVB phototherapy in the treatment of palmoplantar pustulosis: a pilot randomized controlled study. Lasers Med Sci 2017; 32:1819-1823. [DOI: 10.1007/s10103-017-2280-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 06/29/2017] [Indexed: 11/25/2022]
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