Interventions for Chronic Palmoplantar Pustulosis

Abridged Cochrane Systematic Review and GRADE Assessments

G. Obeid; G. Do; L. Kirby; C. Hughes; E. Sbidian; L. Le Cleach


The British Journal of Dermatology. 2021;184(6):1023-1032. 

In This Article

Abstract and Introduction


Background: Palmoplantar pustulosis (PPP) is a chronic inflammatory disease in which sterile and relapsing pustules appear on the palms and soles.

Objectives: To assess the effects of interventions for chronic PPP to induce and maintain complete remission.

Methods: We searched for randomized controlled trials (RCTs), including people with PPP or chronic palmoplantar pustular psoriasis, in the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and eight trials registers up to July 2020. Study selection, data extraction and risk-of-bias assessment were carried out independently by two review authors. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method.

Results: We included 37 RCTs (1663 participants, 76% women, mean age 50 years). Mean treatment duration was 11 weeks. Topical vitamin D derivative may be more effective than placebo in achieving clearance [risk ratio (RR) 7·83, 95% confidence interval (CI) 1·85–33·12; low-certainty evidence from two trials]. Concerning biological therapies, there was little or no difference between etanercept and placebo in achieving clearance (low-certainty evidence from one trial), ustekinumab is less effective than placebo in reducing severity (low-certainty evidence from one trial), and guselkumab (RR 2·88, 95% CI 1·24–6·69) and secukinumab (RR 1·55, 95% CI 1·02–2·35) are probably better in reducing disease severity (moderate-certainty evidence from two and one trial(s), respectively) but may cause more serious adverse events than placebo.

Conclusions: Evidence is lacking for or against major chronic PPP treatments. Risk of bias and imprecision limit our confidence in the results.


Palmoplantar pustulosis (PPP) is a chronic inflammatory disease in which sterile pustules, relapsing over time, appear abruptly on the palms and the soles, often in conjunction with hyperkeratosis and scaling.[1] PPP usually causes itching and a burning sensation, and can also manifest as intense pain when fissuring occurs, interfering with everyday activities and negatively affecting the quality of life (QoL) of the patient.[1] PPP commonly presents in the fifth or sixth decade of life, and is more frequent in women.[2]

The debate about whether psoriasis and PPP should be considered as variants of the same disease or separate conditions is ongoing. The presence of psoriatic lesions elsewhere on the body is highly variable according to studies, ranging from 8% to 73%.[3,4] Smoking is an important risk factor.[5]

PPP is a challenging disease, with no gold standard therapy. A long-term treatment is needed, and none is curative.[6] Possible treatment options include topical agents (topical corticosteroids are considered to be more effective if applied under occlusion)[7] vitamin D derivatives and topical retinoids;[8] phototherapy;[9] and systemic agents, including systemic retinoids and tetracycline antibiotics.[8,9] In severe forms, immunosuppressive treatments such as methotrexate or ciclosporin can be used.[8] More recently, biological agents have been assessed. This review is a summary of the Cochrane review that evaluated interventions for chronic PPP.[10]