Question:

A 44-year old man complained of chronic scaly eruption on the palms and soles for 20 years. He had consulted various doctors without improvement. On examination, pustules and brownish macules were found on his hands as illustrated.

Answer: C. Palmoplantar pustulosis (PPP)

This condition is considered as a localised form of pustular psoriasis though the characteristic plaque of psoriasis with silvery scales may not be evident. There are yellowish sterile pustules on palms and soles with background of hyperkeratosis. The brownish macules represent dried up pustules. The pustules in PPP appear de novo, in contrast to pustules that develop from vesicles in infected pompholyx eczema.

PPP is notoriously difficult to treat. Scraping for fungus and swab for bacterial culture should be performed. Potent topical steroid is used after excluding infection. Topical tar and dithranol are often not helpful. Topical PUVA therapy and systemic therapy with retinoid and methotrexate are indicated in recalcitrant cases.