An Overview of Psoriasis of the Hands and Feet

Understanding Palmoplantar Psoriasis

Psoriasis lesions on hands.
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Psoriasis of the hands and feet, known as palmoplantar psoriasis, is arguably the most difficult type to live with because the itching and pain can interfere with your ability to perform everyday tasks. In fact, simple activities like writing out a grocery list, walking, or even wearing shoes can cause friction and stress that inflame the skin on the hands and feet, making the condition worse.

Palmoplantar psoriasis is its own distinct disease subtype affecting the palms and soles but can co-occur with nail psoriasis in 60% of cases. Moreover, 33% of people with palmoplantar psoriasis will also have psoriasis on up to 10% of their body. The term palmoplantar is derived for the Latin words palmaris (palm of the hand) and plantaris (soles of the feet).

Fortunately, there are steps you can take—both on your own and with the help of your doctor—to ease the symptoms and frustrations of palmoplantar psoriasis.

Symptoms

Psoriasis of the hands and feet is really no different than psoriasis on any other part of the body. It is a disease characterized by the formation of dry, red, scaly lesions called plaques.

Symptoms of psoriasis of the hands and feet include:

  • Well-defined patches of raised, thickened skin
  • Redness and dryness
  • Fine scaling with silvery-white flakes
  • Itching or burning
  • Cracking
  • Bleeding when scratched or abraded
  • Pain

Because the hands and feet are so articulated, the skin between the toes and fingers are vulnerable to peeling, cracking, and bleeding. Routine tasks like washing dishes can dry and inflame the skin, while working on your feet can generate heat, friction, and inflammation that can't help but make your condition worse.

Your toenails and fingernails can also be affected by psoriasis. Over time, the nail plate can begin to thicken, lift, and crumble or develop unsightly pits, ridges, and discoloration.

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

In addition to plaque psoriasis, there are forms of the disease called palmoplantar pustulosis and acrodermatitis continua of Hallopeau (ACH) in which pus-filled blisters develop on the palms, soles, fingers, or toes.

Causes

Psoriasis is an autoimmune disease characterized by an immune system gone awry. For reasons not entirely understood, the immune system will suddenly regard normal skin cells as harmful and launch an inflammatory attack.

The inflammation causes skin cells, known as keratinocytes, to proliferate 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 (called the epidermis) will thicken and develop psoriatic lesions.

Psoriasis, like all autoimmune disorders, is believed to be caused by a combination of genetics (which predispose you to the disease) and environmental triggers (which activate the disease). Common triggers include:

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

With regards to 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 in which plaques spontaneously develop along the line of a trauma. The risk is may be greater in manual labor workers or people with bunions, corns, blisters, or other signs of repetitive foot stress.

Proper skin care can reduce the risk of flares, but this can be difficult for people who work with their hands or need to be on their feet for extended periods of time.

Diagnosis

There is no single lab test or imaging study that can definitively diagnose palmoplantar psoriasis. While the physical symptoms may be enough to diagnose the disease with a high degree of certainty, other causes may need to be ruled out to ensure the proper treatment.

Doctors will not only look for characteristic symptoms of the disease but also associated conditions that either accompany palmoplantar psoriasis or increase its risk. Examples include:

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

If a diagnosis cannot be reached, your doctor may take a tissue sample via a biopsy. Under the microscope, psoriatic skin cells will appear acanthotic (compressed), unlike eczema or other scaly skin conditions.

Pus in a sample of skin affected by palmoplantar psoriasis will indicate infection as the cause is autoimmune rather than bacterial, viral, or fungal.

Differential Diagnoses

A differential diagnosis may also be performed to rule out all other possible causes for your symptoms. Among the diseases that also cause hand and foot lesions are:

Treatment

The treatment of palmoplantar psoriasis is not unlike that of any other form of psoriasis. With that being said, there are variations of treatment that may be more appropriate for the hands and feet. The primary aims of treatment are threefold:

  • To reduce inflammation (locally and/or systemically)
  • To alleviate dryness, flaking, itching, and pain
  • To achieve and sustain disease remission or low disease activity

This involves lifestyle interventions to reduce your risk of flares as well as topical, oral, or injected drugs to reduce the severity of your symptoms. Phototherapy has also proven valuable to the treatment and control of psoriasis.

Mild to Moderate Cases

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

  • Emollient moisturizers: Apply thinly and frequently to treat dry, itchy, flaky skin and help prevent cracking.
  • Salicylic acid: This keratolytic agent, available in lotions, soaps, foot balms, and shampoos, promotes the shedding of scales and reduces thickened plaques.
  • Coal tar: Lotions, creams, and shampoos with this ingredient can reduce inflammation and slow skin growth.
  • Anti-itch creams, containing ingredients like camphor, menthol, or benzocaine
  • Calcipotriene: A vitamin D derivative, this appears to slow the hyperproduction of skin cells and reduce inflammation.
  • Topical corticosteroids: Apply sparingly to temper local inflammation and reduce the size and appearance of plaques.

To improve absorption, a technique called occlusion may be used in which the hands or feet are covered with cling film, plastic gloves, or a plastic bag for several hours or overnight.

Speak with your doctor about the appropriate use of occlusion to prevent skin irritation or the supersaturation of the skin (which may promote infection).

A topical drug sometimes used to treat psoriasis, called anthralin, is not very successful for palmoplantar psoriasis. Anthralin is messy and impractical, requiring prolonged treatments, and may further dry and irritate delicate skin.

Moderate to Serious Psoriasis

Moderate to severe palmoplantar psoriasis may require aggressive therapies that target inflammation in different ways (and, generally, have greater side effects).

These may include topical or oral retinoids, disease-modifying antirheumatic drugs like methotrexate and cyclosporine, and injected biologic drugs like Enbrel (etanercept) and Cosentyx (secukinumab).

The treatments considered most effective for moderate to severe palmoplantar psoriasis are:

  • Methotrexate, taken in pill form and often prescribed as the backbone of treatment
  • Soriatane (acitretin), an oral retinoid used when psoriasis is resistant to treatment
  • Bathwater PUVA, a form of phototherapy in which your hands and feet are soaked in a bath containing psoralen (a light-sensitizing drug) before being exposed to ultraviolet A (UVA) light

Biologic drugs may be used in severe cases, but can sometimes activate rather than suppress palmoplantar psoriasis symptoms. This is especially true with Humira (adalimumab) and Remicade (infliximab).

Coping

Psoriasis usually requires lifelong management. Even beyond medical interventions, there are things you can do on a day-to-day basis do to prevent flares and better cope with treatment:

  • Moisturize your hands and feet frequently: This is especially true after showers and baths, both of which can cause skin dryness.
  • Avoid hot showers or baths: Both can increase circulatory inflammation and promote dryness.
  • Try therapeutic foot and hand baths: Soaking your feet in cool water for 10 to 15 minutes can certainly provide relief, but it may also soften and loosen scales. Adding Epsom salt or oatmeal to the bath may help soothe inflamed skin.
  • Avoid scrubbing: As much as you may want to exfoliate the skin, 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 warm water, apply antibacterial ointment, and seal the wound with an over-the-counter medical glue/liquid bandage.
  • Change your socks: If you are on your feet all day or are prone to sweating, bring an extra pair of socks with you when you leave the house. You can also use talcum powder to keep your feet dry and an antifungal spray to prevent infection in cracked or bleeding skin.
  • Conceal the plaques: Topical concealers like Dermablend Quick-Fix Concealer are made specifically for people with psoriasis. While useful, avoid applying the concealer to areas of broken skin.
  • Lose weight: Excessive adipose (fat-storing) tissue increases the body's inflammatory burden and, with it, the risk of flares. Extra weight also places undue stress on the feet while standing. Speak with your doctor about the appropriate diet and exercise program to shed extra pounds safely.
  • Manage your stress: Stress triggers psoriasis and vice versa. To break the cycle, explore mind-body therapies like meditation, guided imagery, deep breathing, and progressive muscle relaxation (PMR) to help control your emotions. Regular exercise also helps.

Confidence in Social Situations

There is no denying that palmoplantar psoriasis can have an emotional impact, particularly in work or social situations. With hand psoriasis, you may feel self-conscious or embarrassed, say, when shaking hands or when around people who aren't able to hide their uncertainty (or even uneasiness) about your very visible condition. The same can be said if you have psoriasis on your feet, which may prompt you to avoid footwear like sandals and open-toe shoes.

What steps you take, if any, to hide your palmoplantar psoriasis is up to you. If you feel stress in social situations because of your lesions, it may help to remember that showing confidence and not drawing attention to your skin usually means others with follow suit. For example, try to look people directly in the eye rather than staring at your hands. If you feel comfortable doing so, you might also choose to educate others about your condition. While you may focus on it, most people may not even notice your condition if your skin is properly moisturized.

Remember: You have psoriasis, but it doesn't define you.

A Word From Verywell

If you are unable to cope or feel that palmoplantar psoriasis is diminishing your quality of life, speak with your doctor. In some cases, it may be appropriate to treat the disease more aggressively, even if the lesions are small, and/or to seek the help of a therapist or psychiatrist. You may also benefit from joining a support group of people who understand what you are going through. One such option is TalkPsoriasis, a nationwide support community organized by the National Psoriasis Foundation (NPF).

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Article Sources

  1. Miceli A, Schmieder GJ. (2019) Palmoplantar Psoriasis. Treasure Island, Florida: StatsPearl Publishing [Internet].

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