Palmoplantar Pustulosis — SCE Dermatology MCQ

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ModerateInflammatory DermatosesPalmoplantar PustulosisSCE Dermatology

A 38-year-old woman presents with recurrent crops of sterile pustules on erythematous plaques affecting her palms. She has tried potent topical corticosteroids with limited benefit. She is a current smoker. What systemic treatment has the strongest evidence for palmoplantar pustulosis?

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Correct answer: C — Acitretin

Acitretin (oral retinoid) has the most consistent evidence base for palmoplantar pustulosis. BAD guidelines recommend Acitretin 25-50 mg daily as first-line systemic therapy. PUVA (hand/foot soak) is also effective. Interestingly, biologic therapies targeting TNF-alpha may paradoxically trigger or worsen PPP. Smoking cessation should be strongly encouraged as >90% of PPP patients are current or ex-smokers, and smoking is thought to play a pathogenic role through nicotinic acetylcholine receptor activation in eccrine sweat glands. Methotrexate and Ciclosporin are options but have weaker evidence for PPP specifically.

Reference: BAD 2020 Psoriasis Guidelines; BJD PPP Review