An update on therapeutic options for palmoplantar pustulosis: a narrative review and expert recommendations

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.

KEYWORDS:

• Acitretin
• biologics
• combination therapy
• cyclosporin A
• palmoplantar pustulosis
• phototherapy
• topical corticosteroid
• treatment

Article highlights

• This narrative review has shown a brand-new overview of current therapeutic options for PPP.

• PPP has a recurrent disease course and is challenging to treat. There is no standard therapy for PPP treatment.

• Previous studies have supported the efficacy of topical corticosteroids, cyclosporin A, acitretin and phototherapy combination, and biologics.

• Only low-to-moderate quality evidence for their effectiveness and safety was reported from evidence-based medicine.

• We emphasize the importance of choosing therapies according to disease severity, dealing with complications associated with PPP treatments, and managing comorbidities.

• It is hoped that future studies will help us to determine treatments with more convincing evidence and make guidelines for better PPP management.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Abbreviation and acronym list

PPP, palmoplantar pustulosis; IL, interleukin; PAO, pustulotic arthro-osteitis; RCT, randomized controlled trial; BBP, betamethasone butyrate propionate; CSA, cyclosporin A; MTX, methotrexate; TNF, tumor necrosis factor; PGA, Physician Global Assessment; PDE4, phosphodiesterase-4; JAK, Janus kinase; PUVA, psoralen plus ultraviolet light A; PDT, photodynamic therapy; ALA, aminolaevulinc acid; UVB, ultraviolet B; NB-UVB, Narrowband UVB; NSAID, non-steroidal anti-inflammatory drugs; PPPASI, Palmoplantar Pustulosis Area and Severity Index; CBC, complete blood counts; CMP, comprehensive metabolic panel; TB, tuberculosis; HBV, hepatitis B virus; PCR, polymerase chain reaction; MDT, multidisciplinary team

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/1744666X.2023.2185775

Additional information

Funding

This narrative review was funded by CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-059, National High Level Hospital Clinical Research Funding (2022-PUMCH-B-092), and National Natural Science Foundation of China (82073450).