Palmoplantar Psoriasis Affects the Hands and Feet

Psoriasis of the hands and feet, known as palmoplantar psoriasis, is an inflammatory autoimmune disorder that causes scaly, itchy skin patches on the palms and soles. These plaques can crack open and bleed as you walk or perform manual tasks. Even wearing shoes can become incredibly painful and make symptoms worse.

Palmoplantar psoriasis can occur on its own or in addition to psoriasis elsewhere on the body. It can have a significant impact on quality of life and is, unfortunately, more resistant to traditional psoriasis treatments (although newer biologic drugs have shown promise).

This article describes the symptoms and causes of psoriasis on the hands and feet, as well as how palmoplantar psoriasis is diagnosed and treated.

What Does Psoriasis on the Hands and Feet Look Like?

Palmoplantar psoriasis specifically affects the palms and soles. Even so, it manifests with the same symptoms as plaque psoriasis anywhere else.

Psoriasis on the hands and feet may look like:

• Well-defined patches of raised, thickened skin
• Red, dry, and peeling skin
• Fine scaling with silvery-white flakes

Other Symptoms of Palmoplantar Psoriasis

It may also cause:

• Itching
• Burning
• Pain
• Cracking or bleeding when skin is scratched or rubbed

Palmoplantar psoriasis, like all other types of psoriasis, is characterized by episodic flares in which symptoms will spontaneously re-appear or worsen.

Routine tasks like washing dishes can dry and inflame the skin. Working on your feet can also generate heat, friction, and inflammation that can make the condition worse.

Variations and Co-Occurring Conditions

A variation of the disease, called acrodermatitis continua of Hallopeau (ACH), causes pus-filled lesions on the palms, soles, fingers, or toes. It is a subtype of pustular psoriasis.

Palmoplantar co-occurs with nail psoriasis (also known as psoriatic onchodystrophy) in more than 50% of cases. This can cause the nail plate to thicken, lift, and crumble or develop unsightly pits, ridges, and discoloration.

Similarly, around one-third of people with palmoplantar psoriasis will experience psoriasis on other parts of their bodies.

Causes of Palmoplantar Psoriasis

Plantopalmar psoriasis accounts for between 3% and 4% of all psoriasis cases. The underpinning of the disease, however, remains the same as all other forms of psoriasis.

Psoriasis is an autoimmune disease in which the immune system will suddenly target and attack normal skin cells, known as keratinocytes.

The inflammatory attack causes the skin cells to grow at a vastly accelerated rate. As the cells push to the surface of the skin faster than they can be shed, the outermost layer of skin (epidermis) will start to thicken and form plaques.

Psoriasis, like all autoimmune disorders, is thought to be caused by a combination of genetics (which predispose you to the disease) and environmental factors (which trigger the disease).

What Triggers Psoriasis on Hands and Feet?

Common triggers for psoriasis on the hands, feet, or any other part of the body include:

• Emotional stress
• Skin injury (including excess sun exposure)
• Infections (especially strep throat and skin infections)
• Extremely cold, dry weather
• Extremely hot, humid conditions
• Certain medications (including beta-blockers or lithium)

With palmoplantar psoriasis specifically, repetitive stress on the hands or feet—such as wearing rough work gloves or ill-fitting shoes—can trigger a phenomenon known as the Koebner response. This is in when plaques spontaneously develop along the line of a trauma.

The Koebner response is more commonly seen in manual laborers or people with bunions, corns, or blisters on their feet.

Diagnosing Palmoplantar Psoriasis

There is no single lab test or imaging study that can definitively diagnose psoriasis on the hands or feet. Although the physical symptoms and signs may be enough to diagnose the disease with a high degree of certainty, other causes need to be ruled out to ensure the correct diagnosis.

Healthcare providers will not only look for classic signs of the disease but also conditions that commonly accompany palmoplantar psoriasis or increase its risk.

Some things your healthcare provider will look for include:

• Skin plaques on other parts of the body
• Fingernail or toenail involvement
• Episodic flares with periods of low disease activity
• A recent strep infection
• A family history of psoriasis or other autoimmune diseases
• Arthritis, particularly of the hands and feet

If there is any doubt about the diagnosis, your healthcare provider may take a tissue sample via a biopsy. Under the microscope, psoriatic skin cells will appear compressed.

What Else Could It Be?

A differential diagnosis is a process used to rule out all other possible causes of your symptoms. Among the diseases commonly included in a differential diagnosis for palmoplantar psoriasis are:

• Contact dermatitis: A skin reaction caused by contact with irritants or allergy-causing substances
• Eczema: A scaly, itchy skin condition also known as atopic dermatitis
• Hand, foot, and mouth disease: A common childhood viral illness
• Palmoplantar keratoderma: An uncommon genetic disorder that causes the thickening of the palms and soles
• Pityriasis rubra pilaris: A skin condition of unknown origin that causes the inflammation and scaling of the skin
• Secondary syphilis: The second stage of syphilis that can cause the spontaneous outbreak of spots on the palms of the hand.
• Tinea manuum; A fungal infection of the hands similar to athlete's foot
• Tinea pedis: Athlete's foot

How Do You Treat Foot and Hand Psoriasis?

Foot and hand and psoriasis cannot be cured, but it can be managed so that symptoms are less severe and flare-ups are less often.

While palmoplantar psoriasis can be harder to treat than psoriasis of the body, the options are more or less the same. These include the avoidance of psoriasis triggers as well as topical, oral, or injected drugs to reduce the severity of your symptoms.

Mild-to-Moderate Cases

Mild-to-moderate palmoplantar psoriasis may be treated with topical treatments, including:

• Emollient moisturizers: These are applied frequently to the skin to reduce dryness, flaking, itching, and cracking.
• Salicylic acid: Available in lotions, soaps, foot balms, and shampoos, this keratolytic agent help breaks down thickened tissues.
• Coal tar: A century-old remedy available in lotions and creams that can slow skin growth.
• Anti-itch creams: These topical products contain ingredients like camphor, menthol, or benzocaine that reduce itching.
• Calcipotriene: A vitamin D derivative, this drug slows the production of skin cells while reducing inflammation.
• Topical corticosteroids: Also known as steroids, these are applied to the skin to reduce inflammation and temper the overactive immune response.
• Vtama (tapinarof) cream 1%: The first and only FDA-approved nonsteroidal topical drug for mild to severe plaque psoriasis.

A technique called occlusion may also be used. With this, the hands or feet are covered with plastic wrap, plastic gloves, or a plastic bag for several hours or overnight to improve absorption of the topical treatment.

Moderate-to-Severe Psoriasis

Moderate-to-severe palmoplantar psoriasis may require aggressive therapies that target inflammation in specific ways. The options include:

• Methotrexate: Taken in pill form, this drug slows the production of cells and is often used as the cornerstone of palmoplantar psoriasis treatment.
• Soriatane (acitretin): An oral drug derived from vitamin A that is used when psoriasis is resistant to other treatments.
• Bathwater PUVA: This is a form of phototherapy in which your hands or feet are soaked in a bath containing psoralen (a light-sensitizing drug) before being exposed to ultraviolet (UV) light.
• Biologic drugs: These agents temper parts of the immune system linked to psoriasis. They include injectable drugs like Enbrel (etanercept), Cosentyx (secukinumab), and Humira (adalimumab).

Coping With Palmoplantar Psoriasis

Psoriasis usually requires lifelong management. Even beyond medications, there are things you can do to prevent hand and foot psoriasis flares and better cope with treatment:

• Avoid hot showers or baths: Hot water increases inflammation and promotes dryness.
• Moisturize frequently: This is especially true after showers and baths.
• Avoid alcohol-based hand sanitizers: These can rob your skin of moisture and make psoriasis worse. Instead, use gentle soap and water, and moisturize after.
• Try a foot bath: Soaking your feet in cool water for 10 to 15 minutes can reduce pain, as well as soften and loosen scales. Adding Epsom salt or oatmeal may help soothe inflamed skin.
• Avoid scrubbing: Scrubbing with a brush or loofah can cause splitting and bleeding. Instead, use your hands or a soft washcloth to gently remove scales after soaking.
• Treat broken skin: Cracks between the fingers and toes are hotbeds for infection. Clean any broken skin with soap and water, apply an antibacterial ointment, and seal wounds with an over-the-counter medical glue or liquid bandage. Avoid picking.
• Apply sunscreen: A sunburn can trigger a flare-up of psoriasis. Before going outdoors, apply sunscreen to the hands and feet (as well as the face and body) with a minimum sun protection factor (SPF) of 30.
• Avoid going barefoot: An abrasion may not only compromise the skin barrier but trigger a psoriasis flare. Reduce your risk by wearing the appropriate shoes, especially when outdoors.
• Change your socks: If you are on your feet all day, or are prone to sweating, bring an extra pair of socks with you. You can also use talcum powder to keep your feet dry and an antifungal spray to prevent infection in cracked or bleeding skin.
• Wear gloves: During a flare-up, soft cotton gloves can be soothing and help retain moisture when you use lotion. Rubber gloves can protect your hands while washing dishes. Some people also use disposable gloves for occlusive therapy to keep topical medications on the skin longer.
• Use a concealer: Topical concealers like Dermablend Quick-Fix Concealer are made specifically for people with psoriasis. While useful, avoid applying the concealer to broken skin.
• Lose weight: Excess body fat increases whole-body inflammation and the risk of flares. Extra weight also places undue stress on the feet while standing.
• Manage stress: Stress triggers psoriasis and vice versa. To break the cycle, explore mind-body therapies like meditation, guided imagery, and deep breathing exercises. Regular exercise also helps.