YANMWD - plantar pustular psoriasis, 2014 edition

August 25, 2014 8:04 AM

Mrs Peteyjlawson was diagnosed with plantar pustular psoriasis a few years ago. Nothing the doctors have suggested has helped. Members of the green, any tips for reducing or managing this condition? Snowflakes inside.

My lovely wife has been suffering with this for a long time, but it's reaching a point where it's affecting her quality of life quite badly. She has a large patch that takes up most of the instep of one foot and a smaller patch on the sole of her other foot. Topical steroids do nothing. Salt baths and constant moisturising manage the condition a little, but she can't walk for extended periods of time before being in considerable pain. Two GPs have been unhelpful to say the least (one of them prescribed vitamin D cream which was specifically contraindicated for pustular psoriasis in the SMPC, the other pretty much said 'just live with it'). She's also been recently diagnosed with PCOS which Google suggests may be somewhat connected. We aren't big fans of alternative medicine and we're planning on getting a referral to a specialist. Before we do, have any Mefi members got any experience with the pustular version of the condition, and do any of you have any management strategies or miracle cures we could try? Thanks in advance for any help offered.

posted by peteyjlawson to Health & Fitness (12 answers total)

My mother had psoriasis all over. The only thing that helped was medication to inhibit her immune system. Embrel is an amazing drug. But it is very expensive and my mother had a host of other systems as well including psoriasic arthritis.
posted by AlexiaSky at 8:16 AM on August 25, 2014 [1 favorite]

GPs usually can't manage anything more than mild psoriasis -- it's just not in their expertise or experience. A good dermatologist should be able to explore other treatments beyond topical steroids, including but not limited to biologic treatments like AlexiaSky mentioned.
posted by telegraph at 8:20 AM on August 25, 2014 [1 favorite]

I have found dietary intervention most effective for managing my various skin issues. In my case, a paleo/whole30 type elimination diet helped most when steroids and moisturizers weren't having any effect. YMMV, IANADietician/Dermatologist etc.
posted by lizifer at 8:55 AM on August 25, 2014 [1 favorite]

You wife definitely needs a dermatologist. I have plaque psoriasis, and at one point had it on my feet, although (thank goodness!) it cleared up. In collaboration with a specialist, your wife will want to examine biologic treatments like Enbrel (which is amazing, like AlexiaSky said, but can be hard to manage). You don't mention whether your wife has tried phototherapy. It sounds like woo, but it really works. A dermatologist might administer phototherapy in the office, using special lamps.

But while she is waiting for the specialist, your wife might want to try getting lots of sun exposure on the affected parts of her feet, even to the point of sunburn. I do this by putting sunblock on all my skin that doesn't have psoriasis, then sitting in the sun for a long time. For me, about 10 days of that clears up all my psoraisis, but even lessor amounts of exposure improve my symptoms.
posted by OrangeDisk at 9:06 AM on August 25, 2014 [1 favorite]

Seconding lizifer here. I have had weird skin problems for years, including psoriasis on various parts of me and pustular psoriasis on my hands and feet. I've tried just about everything under the sun--including lots of sun. In June I eliminated gluten, dairy, and sugar from my diet, and by the end of July all but the most pernicious patches were gone. After YEARS of torment! Thinking I was in the clear, I embarked on WheatFest 2014 and ate bread, pasta, etc. for about four days. And . . . it all came back. YMMV/everybody's different, but to me the difference was immediate and noticeable. I'm now a firm believer in diet being the single greatest factor in controlling psoriasis.
posted by fiery.hogue at 9:32 AM on August 25, 2014 [2 favorites]

My husband's psoriasis was finally largely controlled by prescription of an immune-suppresent med-initially Embrel and now Humira that was prescribed for his Crohn's. Insanely expensive, but covered in full by our good insurance. He does notice an increase in symptoms (itchiness and skin problems) when he has gluten.
posted by purenitrous at 9:38 AM on August 25, 2014

Mine is controlled with sulfasalazine. See a dermatologist, or possibly a rheumatologist / immune-disorders specialist if there are any joint / tendon pains.
posted by blue_wardrobe at 10:12 AM on August 25, 2014

My husband has psoriasis of the scalp that was initially misdiagnosed as dandruff. He started methotrexate after he developed psoriatic arthritis, and the scalp psoriasis disappeared. He also takes a large folic acid supplement to help mitigate the side effects from the methotrexate, and as a result has almost none. I'd seek out a rheumatologist (psoriasis is an autoimmune disease) and ask about methotrexate therapy.
posted by KathrynT at 10:25 AM on August 25, 2014 [1 favorite]

See a dermatologist, but one who doesn't shy away from more aggressive therapy if it is necessary. She'll probably first be placed on methotrexate and/or phototherapy, and if she doesn't respond to that then the biologic drugs are a next step.

(I work for one of the pharma companies that makes a biologic to treat psoriasis but I have no personal experience myself so I won't name any names of products to try)
posted by photovox at 1:27 PM on August 25, 2014

Best answer: Some now believe PPP to be a distinct entity:

PPP was thought to be a localised form of pustular psoriasis but about 10-20% of patients with PPP have psoriasis elsewhere. It is therefore now considered that they are distinct conditions with different genetic backgrounds.[1].

associated with other health issues:

The condition occurs much more commonly in smokers and ex-smokers. It may run in families and rarely occurs in childhood. Gluten sensitivity and tonsillar streptococcal infection have been implicated in some cases.[5]

Successful treatment is hard to come by:

Palmoplantar pustulosis (PPP) is difficult to treat. There is little hard evidence for the efficacy of any treatment and no published guidelines for its management. A number of exacerbating factors are well documented and there is some evidence for the importance of others. Smoking is the most recognized environmental trigger and recent research has concentrated on the role of eccrine sweat glands in this regard. Other factors, including tonsillar streptococcal infection and gluten sensitivity, may be important in selected cases.

Tonsillectomy has helped some people:

Palmoplantar pustulosis (PPP) is famous for causing typical tonsillar focal diseases. Clinical improvement of PPP rash after tonsillectomy was seen in 109 (94%) of 116 patients by subjective self-assessment, and 52 (88%) of 59 patients by objective Palmoplantar Pustulosis Area and Severity Index (PPPASI) scoring

But PPP can also be associated with other infections:

Although the pathogenesis of PPP is still poorly understood, PPP is a representative skin disorder showing a close relationship with focal infections such as tonsillitis, chronic sinusitis, and dental infection. In particular, tonsillitis often triggers or deteriorates PPP.

I'd say her PCOS could be playing a role in her PPP because of the increased adrenal activity often found in PCOS, since the eccrine sweat glands in the hands and feet (mentioned in the third excerpt above) have α1 adrenergic receptors.
posted by jamjam at 2:39 PM on August 25, 2014 [2 favorites]

I have several forms of psoriasis, all of which respond well to both steroid treatments and lifestyle interventions (provided I stick to them...). However, I do not have PPP and I get the impression that the symptoms and treatments are not the same as commonly recommended for plaque/scalp/inverse/guttate/whatever psoriasis.

So, just to add to what jamjam says, please do see a specialist as soon as you can wangle one - GPs tend to only be prepped in treating mild, 'standard' plaque psoriasis. Dermatologists are not only better informed of treatments for PPP and other atypical psoriasis-adjacent conditions, they are much more aware of the debilitating fallout of having an autoimmune skin condition and are more likely to, at the very least, sympathise with your wife rather than minimise her experience with this condition.

PS. FWIW, a dietary intervention like the Whole30 suggested above helped me with many things, but psoriasis was not one of them. YMMV and it doesn't hurt to try an exclusion diet.
posted by dumdidumdum at 11:41 AM on August 26, 2014

Response by poster: Thanks for the input folks, as usual, you were all awesome. We're waiting for a referral to a specialist and will discuss the options you've all presented here to see if we can manage the condition a bit better.
posted by peteyjlawson at 11:06 AM on August 27, 2014