Overview of Plantopalmar Psoriasis

How to Cope with Psoriasis of the Hands and Feet

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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. It is not only hard to conceal but can interfere with your ability to function normally. The itching and pain can interfere with your ability to walk or perform certain manual tasks. In fact, the very act of walking, wearing shoes, or doing manual labor can cause friction and other stresses that inflame the skin and make your condition worse.

The lesions, redness, and scaling are not only physically challenging but can cause extreme emotional distress. Even simple tasks like shaking hands can cause embarrassment or, worse yet, trigger alarm from those around you.

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 plantopalmar 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 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. Everyday 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 will 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 the characteristic 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)

Alcohol and smoking are also known to increase your risk of the disease.

With respect to the hands and feet specifically, abrasions, friction, or even vigorous scratch can trigger a phenomenon known as the Koebner response in which plaques spontaneously develop along the line of a trauma.

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 are no single lab tests or imaging studies 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.

Some of the tell-tale signs a doctor may look for 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.

If there is pus, a sample would reveal no signs of infection since 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 Psoriasis

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

  • Emollient moisturizers, applied thinly and frequently to treat dry, itchy, flaky skin and help prevent cracking
  • Salicylic acid, a keratolytic agent available in lotions, soaps, foot balms, and shampoos, to promote the shedding of scales and reduce thickened plaques
  • Coal tar, applied to the skin in lotions, creams, and shampoos, to reduce inflammation and slow skin growth
  • Anti-itch creams, containing ingredients like camphor, menthol, or benzocaine
  • Calcipotriene, a vitamin D derivative that appears to slow the hyperproduction of skin cells and reduce inflammation
  • Topical corticosteroids, applied sparingly to temper local inflammation and reduce the size and appearance of plaque

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 trued with Humira (adalimumab) and Remicade (infliximab).

Coping

Psoriasis usually requires lifelong management. Even beyond medical interventions, there are things you can 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 may also soften and loosen scales. Adding Epsom salt or oatmeal to the bath may also 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 like New-Skin Liquid Bandage.
  • Change your socks. If you are on your feet all day or are prone to sweating, bring an extra pair of socks to work to change into. 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) tissues increase 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 those extra pounds safely.
  • Manage your stress. Stress triggers psoriasis, and psoriasis triggers stress. 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.

There is no denying that palmoplantar psoriasis can cause extreme emotional distress, particularly in work or social situations. The truth is you can't always hide your condition or greet people with a knuckle-bump instead of a handshake.

One of the best ways to reduce stress in social situations is to look people directly in the eye rather than glancing at your hands. As long your hands are properly moisturized, most people will not even notice or pay little mind to your condition.

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 actual size of the lesions is small.

It also helps to seek emotional support from friends and family or to join 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). Other groups can be found on Facebook or through your local NPF chapter.

If experiencing persistent depression or anxiety, ask your doctor for a referral to a therapist or psychiatrist who can offer counseling and the appropriate medications if needed.

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