Palmoplantar psoriasis

Kumar B, Kumar R, Kaur I. 1997. Coal tar therapy in palmoplantar psoriasis old wine in an old bottle Int J Dermatol 36 309-312. 

Skin In a retrospective comparison of UVBTLOl phototherapy and PUVA therapy in patients with palmoplantar psoriasis, UVBTLOl was associated with adverse reactions in 20% of cases (erythema 18%, first-degree bums 7%) and treatment was discontinued in 4% PUVA therapy was associated with adverse reactions in 50% of patients and was mainly attributable to methoxypsoralen [63 ]. 

Redon E, Bursztejn A-C, Loos C, Barbaud A, Schmutz J-L. Etude retrospective de I efficacite et de la tolerance de la phototh6rapie UVBTLOl et de la PUVA th6rapie dans le psoriasis palmoplantaire. [A retrospective efficacy and safety study of UVB-TLOl phototherapy and PUVA therapy in palmoplantar psoriasis.] Ann Dermatol Venereol 2010 137(10) 597-603. 

A 45-year-old woman took dapsone 150 mg/ day for 5 weeks for pustular palmoplantar psoriasis and developed dyspnea, numbness of all four limbs, and syncope. She had multiple enlarged mobile cervical and retroauricu-lar lymph nodes measuring 1.5-3.0 cm and an itchy maculopapular rash. Her liver enzymes were raised but urea and electrolytes were normal. An electrocardiogram showed sinus rhythm and left anterior fascicular block. She had three further episodes of syncope, on each occasion associated with bradycardia. Dapsone was withdrawn and she was given atropine, dopamine, and isoprenaline, but her heart rate and blood pressure remained low and eventually a pacemaker was inserted. 

Acitretine ch3o x x Oral 0.25-1.0 mg/kg/d Psoriasis (erythrodermic, pustular, and severe recalcitrant) Palmoplantar keratoderma pustulosis palmoplantaris, icthyosis, Darier s disease, pityriasis rubra pilaris, lichen ruber planus... 

Acitretin is most useful for the treatment of severe psoriasis, particularly the pustular and erythrodermic variants. Psoriatic nail changes and arthritis also may respond. Combining the drug with ultraviolet light therapy (Re-UVB, in the case of ultraviolet B radiation, or Re-PUVA, with psoralen plus ultraviolet A radiation) permits the use of lower doses of both acitretin and ultraviolet radiation. Other conditions for which the drug may be especially useful include congenital and acquired hyperkeratotic disorders, such as the ichthyoses and palmoplantar keratodermas, and severe lichen planus. 

In 1990, etretinate (Tigason) was replaced by acitretin (Neo-Tigason), an aromatic retinoid, a carboxylic acid metabolite of etretinate (15). It is effective in pustular psoriasis and psoriatic palmoplantar keratoderma and in combination with PUVA or topical therapy (calci-potriol or glucocorticoids) in the treatment of other forms of psoriasis. It has also been used to treat disorders of keratinization (ichthyosis, palmoplantar keratoderma, Darier s disease) and severe cutaneous forms of lichen planus. It prevents new skin carcinomas in patients with xeroderma pigmentosum and those who are immunosuppressed. The main advantage of acitretin is its short half-life of 50 hours, compared with over 80 days for etretinate (16). 

Forty-two patients with palmoplantar pustulosis, including 21 with psoriasis elsewhere on the body, responded well to etretinate at an initial dosage of 75 mg/ day. Pustules healed within 2 weeks but recurred in some patients within 2 weeks of stopping therapy. Other patients with complete remissions had prolonged remissions lasting as long as 6 months (Thune, 1982). 

Paradoxical inflammation such as psoriasis is a well-known phenomenon of anti-TNFa therapy approved for the treatment of autoimmxme diseases such as rheumatoid arthritis, Crohn s disease, ulcerative colitis and psoriasis. Likewise, infliximab is used to treat refractory sarcoidosis but recently a case of infliximab-induced cutaneous sarcoidosis was reported in a patient with ulcerative colitis [150 ]. The induction of psoriasis and other clinical presentations like psoriasiform exanthema and palmoplantar pustulosis as side effects of infliximab treatment is not xmderstood and the pathogenesis of such reactions has been further obscured by the finding of a patient with Crohn s disease who developed arthritis as well as the skin manifestations cf psoriasis after the administration of infliximab [151 ]. 

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