Psoriasis on Hands and Feet

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Appearance and Types

The appearance of psoriasis on the hands and feet can manifest themselves as cracks, blistering and swelling.

Chronic Plaque discoid psoriasis – raised, red , scaly patches mainly involving the limbs and the trunk, especially on the elbows, knees, hands, around the navel, over the lower back (sacrum) and on the scalp. The nails may affected so that they become thickened and raised from their nail beds, The surface of the nail may be marked with small indentations. This is the most common type of psoriasis affecting approximately 9 out of 10 sufferers.

Guttate psoriasis - numerous small red scaly patches quickly develop over a wide area of skin, although the palms and the soles are usually not affected. This occurs most frequently in children, often after a throat infection due to streptococcal bacteria. Some patients will go on in later life to develop chronic plaque psoriasis

Erythrodermic Psoriasis – sometimes may occur with von Zumbusch (generalised pustular) psoriasis. It is an active inflammatory form of psoriasis that can affect most parts of the body surface. Its appearance can be widespread angry redness of the affected skin. The shedding of the affected skin area can also be associated with severe pain and itching. Erythrodermic Psoriasis can also cause fluid and protein loss leading to severe illness. Swelling from fluid retention (oedema) may also be found around the ankles and can also develop together with infection. The temperature of the body can also be disrupted causing outbreaks of shivers. Infection, pneumonia and congestive heart failure that may be brought on by erythrodermic psoriasis can be serious.

Triggers can include abrupt withdrawal of systemic treatments, the use of systemic steroids, allergic drug induced rashes that trigger the Koebner response and severe sunburn.

Localised pustular psoriasis - Localised pustular psoriasis is also known as Palmo-plantar pustular psoriasis because it affects the palms of the hands and soles of the feet. Affected skin is usually red and scaly with yellowish pustules just under the skin surface.

These pustules are sterile which means they are not the result of infection. Antibiotics do not affect them. After a time, the pustules dry up and resolve to leave brown stains on the skin surface. The natural history of the disease is usually cyclical, with the appearance of new crops of pustules followed by periods of low activity in which the pustules resolve.

Palmo-plantar pustular psoriasis
affects about 5% of people with psoriasis. It occurs most commonly between the ages of 20 and 60 years. It can be painful, and is more common in women than men. About 10-25% of people with it have a positive family history but the precise reason why some people develop it is not known. It causes pustules on the palms and soles of the feet. Infection and stress are suspected trigger factors. PPP is normally recognisable by large yellow pustules up to 5cms in diameter, in fleshy areas of hands and feet, such as the base of the thumb and the sides of the heels. They then turn brown and drop-off or peel. PPP is usually clinical with new crops of pustules followed by periods of low activity.

It tends to go in cycles of:

1.Erythema (reddening of the skin) followed by
2.Formation of pustules and
3.Scaling of the skin.

It is often difficult to treat, although some patients do benefit from strong topical steroids combined with tar preparations. However, in most cases treatment with acitretin (a vitamin A derivative) tablets is the most effective.

Acrodermatitis Continua of Hallopeau is a very rare form of localised pustular psoriasis. This looks similar to palmo-plantar pustular psoriasis but is localised to the ends of the fingers and less commonly the toes (acropustulosis). It usually starts after some trauma to the skin. It tends to be painful and frequently affects the nails. It may lead to loss of the nails. Bone changes can be seen in severe cases. It is difficult to treat and many therapies have been tried in the past. Topical treatments are usually not very successful but occasionally systemic medications may help to clear the lesions and restore the nails.