- Email: [email protected]
On the nosology of palmoplantar psoriasis
Letters
On the nosologp of palmoplantar
to the Editor
psoriasis
(ii) plaque-type psoriasis of palms and soles (Fig. 2);
To the Editor: Every psoriatic patient has his own psoriasis. A major question is whether the different manifestations of psoriasis represent different forms of a single disease or whether they are different disease entities. As diKerent manifestations may coexist in an individual, as different manifestations may appear at different times in a patient’s life and as different members within a family may show different manifestations it seems appropriate to characterize psoriasis as a spectrum of one disease entity. It is convenient to consider a 3dimensional spcctrum with guttate psoriasis, chronic plaque psoriasis, erythrodermic psoriasis and pustular psoriasis as extreme manifestations [I]. The position or an individual patient can be considered as a point within this spectrum. The situation, however, is controversial with respect to the palmoplantar manifestations. Some authors regard palmoplantar pustulosis as a separate entity [2,3], while others describe this condition as chronic palmoplantar pustular psoriasis [4]. Erythematosquamous plaques with fissuring of palms and soles is indicated as “eczema hyperkeratoticum rhagadiforme” or “plaque psoriasis 01” palms and soles” [l]. We would like to propose the following classification for psoriasiform eruption of palms and soles: (i) pustulosis palmoplantaris (Fig. 1);
Fig. 1. Fustulosis
(iii) keratoderma-type psoriasis of palms and soles. From a morphological point of view these 3 phenotypes may be interpreted as manifestations of psoriasis with a different expression of cutaneous inflammation and epidennal differentiation. The pustular eruption is tie expression of major inflammatory changes, the more hyperkeratotic condition is the expression of major changes in epidermal differentiation, whereas the erythematosquamous condition has a more intermediate position. At the histological level the pustules have a highly characteristic spongiform appearance, which constitutes a specific histiological hallmark of the psoriatic lesion. The hyperkeratotic form and erythematosquamous form of palmoplantar psoriasis are characterized by multiple parakeratotic foci and the typical psoriatic architecture. Therefore, the clinical and histological appearances of the palmoplantar manifestation as described in this communication are psoriasiform. The question, however, remains to be answered whether the psoriasiform appearance results from a single psoriatic etiology. Nail involvement or the presence of typical psoriatic lesions elsewhere in addition to the palmoplantar manifestations may provide evidence for a psoriatic constitution. Although a sharp demarcation of erythematosquamous lesions or the characteristic histol-
palmoplantaris
Letters to the Editor
Fig. 2. Plaque-type
psoriasis of palms and soles.
ogy may provide further evidence for the diagnosis of psoriasis, many erythematosquamous lesions of palms and soles are isolated presentations and remain without a diagnosis. Various authors reported on the presence of psoriatic lesions elsewhere in patients with palmoplantar pustulosis. Ashurst rcported the presence of psoriatic lesions elsewhere on the body in 2% of patients with palmoplantar pustulosis [5]. Everall, in contrast, reported such lesions in 19% of their patients [6]. The reason for this discrepancy is the difficulty in interpreting minimal psoriasiform changes, such as a few pits of the nailplate, some scaling of the scalp, etc. Therefore the presence or absence of psoriatic lesions elsewhere only provides circumstantial evidence for a psoriatic idcntity. Several HLA linkage studies have been carried out in patients with palmoplantar pustulosis. HLAB13 and -B17 are associated with psoriasis but do not associate with pustulosis palmoplantaris [7-91. A positive association was reported between HLA-BS and palmoplantar pustulosis [S]. So far no linkage studies are available for the erythematosquamous and hyperkeratotic conditions of palms and soles. Therefore, palmoplantar pustulosis is different from psoriasis and no genetic evidence is available lo characterize the erythematosquamous lesions of palm and soles as psoriasis.
Based on epidemiological and genetic aspects of patients with a psoriasiform involvement of palms and soles, we propose avoidance of terms like localized pustular psoriasis, chronic palmoplantar pustular psoriasis and palmoplantar psoriasis. On the other hand, the psoriasiform appearance, the response to antipsoriatic treatments and the responsiveness to factors, which are known to trigger psoriasis, suggest a relationship with psoriasis. Therefore, we propose that the psoriasiform eruption of palms and soles be considered an expression of the phenotypical resemblance of 3 different disease entities: pustulosis palmoplantaris, plaque-type psoriasis of palms and soles, and keratoderma-type psoriasis. P.C.M. Feind
Van de Kerkhof
*, A.L.A.
Kuijpers,
Departntent of Dermatology, lJni~‘ersi~ Hospital Box 9101, 6.500 HE Nijmegen, The Netherlands
A. Kaopmans-
Nijmegen.
P.O.
[l] Van de Kerkhof PC’M. Clinical features. Jn: Mier PD, Van de Kerkhof PCM, Textbook of Psoriasis. eds. Churchill Livingstone, Edinburgh, 1986:13-39. [2] Andrew GC, Birkman FW, Kelly RJ. Recalciuanl pustular eruptions of palms and soles. Arch Dermarol Syph, 1934;29:548-563. [3] Barber HW. Acrodermatitis continua vel perstans (dermatitis repens) and psoriasis pustulosa. Fir J Dermatol 1930;42:500518.
Camp RDR. Psoriasis. In: Champion RH, Burton JL. Ebling FJG. eds. Texthook of Dermatology. Blackwell Scientific Publications, Oxford, 1992:1391-1457. iSI Ashurst PJC. Relapsing pustular eruption5 of the hands and feet. Arch Dermatol 1964:76:16Y-179. t61Everall I. Intractable pustular eruptions of the handsand feet. Br J Dermatol 1957:69:269-272. [71 Swjgaard A, Nielsen L, Svejgaard E, Kissmcijer-Nielsen F, Hjortskgj. A, Zachariae H. HLA in psoriasis vulgaris and in pustular psoriasis-populationand family studies.Br J Dermato1 1973;91:145-153. [81Karvonen J, Tiilikainen A, LassusA. HLA antigensin psoriasis. In: Farber EM, Cox AJ, Jacobs PII, NalI ML, eds.
Psoriasis. Proc 2nd Int Symp. Yorke Medical Books: New York, 1977:405-408. [9] Ward JM. Barnes RMR. HLA antigens in persistent palmoplantar puslulosiaand its relationship lo psoriasis.Br J Derrmto1 1978:YY:477-483.
Pigmentatio maculosa multiplex: a variant of ashy dermatosis?
PMM is a distinctive appearing, yet relatively rare, dermatosisbelonging to the disordersof melanin pigmentationoccurring most frequently in Japan[l].
To Ihe E&far: Pigmentalio maculosa multiplex (PMM) is a rare condition of unknown etiology and pathogenesis.There are several reports proposing a possible relationship between PMM and erythema dyschromicumperstans(ashy dermatosis).We report a typical case of PMM and discuss the differential diagnosis. A lo-year-old boy presentedwith a j-year history of asymptomatic,hyperpigmented,maculareruptions initially arising on the abdomen and then slowly progressingto involve the entire body, sparing only the scalp, palms, and soles. His general health was excellent, and he had no significant drug history. There was no family history of cutaneous disease.Physicalexamination revealed well defined, homogeneous,brown and bluish gray. roundish and oval ma&es 5-25 mm in diameter(Fig. 1). Lesions involved the face, neck, trunk and extremities, but the mucous membranesremained clear. All lesions were uniform maculeswithout erythema.Results of the laboratory studiesindicated a normal hemogram and a normal corticosteroidendocrinesystem.Histological examination showed pigment incontinence with melanophagesand a mild perivascular chronic inflammatory infiltrate in the upper dermis (Fig. 2). Montana-Massonstaining showed that the hyperpigmented area had melanin present in both the basal areaand the upper dermis.A diagnosisof PMM was made.
x Correspondmgauthor
PIZ SO926-9959(96)00040-2
Fig. 1. Numerous,well demarcated,oval and roandish. brown and bluish gray maculesand patcheson the trunk.
On the nosologp of palmoplantar
to the Editor
psoriasis
(ii) plaque-type psoriasis of palms and soles (Fig. 2);
To the Editor: Every psoriatic patient has his own psoriasis. A major question is whether the different manifestations of psoriasis represent different forms of a single disease or whether they are different disease entities. As diKerent manifestations may coexist in an individual, as different manifestations may appear at different times in a patient’s life and as different members within a family may show different manifestations it seems appropriate to characterize psoriasis as a spectrum of one disease entity. It is convenient to consider a 3dimensional spcctrum with guttate psoriasis, chronic plaque psoriasis, erythrodermic psoriasis and pustular psoriasis as extreme manifestations [I]. The position or an individual patient can be considered as a point within this spectrum. The situation, however, is controversial with respect to the palmoplantar manifestations. Some authors regard palmoplantar pustulosis as a separate entity [2,3], while others describe this condition as chronic palmoplantar pustular psoriasis [4]. Erythematosquamous plaques with fissuring of palms and soles is indicated as “eczema hyperkeratoticum rhagadiforme” or “plaque psoriasis 01” palms and soles” [l]. We would like to propose the following classification for psoriasiform eruption of palms and soles: (i) pustulosis palmoplantaris (Fig. 1);
Fig. 1. Fustulosis
(iii) keratoderma-type psoriasis of palms and soles. From a morphological point of view these 3 phenotypes may be interpreted as manifestations of psoriasis with a different expression of cutaneous inflammation and epidennal differentiation. The pustular eruption is tie expression of major inflammatory changes, the more hyperkeratotic condition is the expression of major changes in epidermal differentiation, whereas the erythematosquamous condition has a more intermediate position. At the histological level the pustules have a highly characteristic spongiform appearance, which constitutes a specific histiological hallmark of the psoriatic lesion. The hyperkeratotic form and erythematosquamous form of palmoplantar psoriasis are characterized by multiple parakeratotic foci and the typical psoriatic architecture. Therefore, the clinical and histological appearances of the palmoplantar manifestation as described in this communication are psoriasiform. The question, however, remains to be answered whether the psoriasiform appearance results from a single psoriatic etiology. Nail involvement or the presence of typical psoriatic lesions elsewhere in addition to the palmoplantar manifestations may provide evidence for a psoriatic constitution. Although a sharp demarcation of erythematosquamous lesions or the characteristic histol-
palmoplantaris
Letters to the Editor
Fig. 2. Plaque-type
psoriasis of palms and soles.
ogy may provide further evidence for the diagnosis of psoriasis, many erythematosquamous lesions of palms and soles are isolated presentations and remain without a diagnosis. Various authors reported on the presence of psoriatic lesions elsewhere in patients with palmoplantar pustulosis. Ashurst rcported the presence of psoriatic lesions elsewhere on the body in 2% of patients with palmoplantar pustulosis [5]. Everall, in contrast, reported such lesions in 19% of their patients [6]. The reason for this discrepancy is the difficulty in interpreting minimal psoriasiform changes, such as a few pits of the nailplate, some scaling of the scalp, etc. Therefore the presence or absence of psoriatic lesions elsewhere only provides circumstantial evidence for a psoriatic idcntity. Several HLA linkage studies have been carried out in patients with palmoplantar pustulosis. HLAB13 and -B17 are associated with psoriasis but do not associate with pustulosis palmoplantaris [7-91. A positive association was reported between HLA-BS and palmoplantar pustulosis [S]. So far no linkage studies are available for the erythematosquamous and hyperkeratotic conditions of palms and soles. Therefore, palmoplantar pustulosis is different from psoriasis and no genetic evidence is available lo characterize the erythematosquamous lesions of palm and soles as psoriasis.
Based on epidemiological and genetic aspects of patients with a psoriasiform involvement of palms and soles, we propose avoidance of terms like localized pustular psoriasis, chronic palmoplantar pustular psoriasis and palmoplantar psoriasis. On the other hand, the psoriasiform appearance, the response to antipsoriatic treatments and the responsiveness to factors, which are known to trigger psoriasis, suggest a relationship with psoriasis. Therefore, we propose that the psoriasiform eruption of palms and soles be considered an expression of the phenotypical resemblance of 3 different disease entities: pustulosis palmoplantaris, plaque-type psoriasis of palms and soles, and keratoderma-type psoriasis. P.C.M. Feind
Van de Kerkhof
*, A.L.A.
Kuijpers,
Departntent of Dermatology, lJni~‘ersi~ Hospital Box 9101, 6.500 HE Nijmegen, The Netherlands
A. Kaopmans-
Nijmegen.
P.O.
[l] Van de Kerkhof PC’M. Clinical features. Jn: Mier PD, Van de Kerkhof PCM, Textbook of Psoriasis. eds. Churchill Livingstone, Edinburgh, 1986:13-39. [2] Andrew GC, Birkman FW, Kelly RJ. Recalciuanl pustular eruptions of palms and soles. Arch Dermarol Syph, 1934;29:548-563. [3] Barber HW. Acrodermatitis continua vel perstans (dermatitis repens) and psoriasis pustulosa. Fir J Dermatol 1930;42:500518.
Camp RDR. Psoriasis. In: Champion RH, Burton JL. Ebling FJG. eds. Texthook of Dermatology. Blackwell Scientific Publications, Oxford, 1992:1391-1457. iSI Ashurst PJC. Relapsing pustular eruption5 of the hands and feet. Arch Dermatol 1964:76:16Y-179. t61Everall I. Intractable pustular eruptions of the handsand feet. Br J Dermatol 1957:69:269-272. [71 Swjgaard A, Nielsen L, Svejgaard E, Kissmcijer-Nielsen F, Hjortskgj. A, Zachariae H. HLA in psoriasis vulgaris and in pustular psoriasis-populationand family studies.Br J Dermato1 1973;91:145-153. [81Karvonen J, Tiilikainen A, LassusA. HLA antigensin psoriasis. In: Farber EM, Cox AJ, Jacobs PII, NalI ML, eds.
Psoriasis. Proc 2nd Int Symp. Yorke Medical Books: New York, 1977:405-408. [9] Ward JM. Barnes RMR. HLA antigens in persistent palmoplantar puslulosiaand its relationship lo psoriasis.Br J Derrmto1 1978:YY:477-483.
Pigmentatio maculosa multiplex: a variant of ashy dermatosis?
PMM is a distinctive appearing, yet relatively rare, dermatosisbelonging to the disordersof melanin pigmentationoccurring most frequently in Japan[l].
To Ihe E&far: Pigmentalio maculosa multiplex (PMM) is a rare condition of unknown etiology and pathogenesis.There are several reports proposing a possible relationship between PMM and erythema dyschromicumperstans(ashy dermatosis).We report a typical case of PMM and discuss the differential diagnosis. A lo-year-old boy presentedwith a j-year history of asymptomatic,hyperpigmented,maculareruptions initially arising on the abdomen and then slowly progressingto involve the entire body, sparing only the scalp, palms, and soles. His general health was excellent, and he had no significant drug history. There was no family history of cutaneous disease.Physicalexamination revealed well defined, homogeneous,brown and bluish gray. roundish and oval ma&es 5-25 mm in diameter(Fig. 1). Lesions involved the face, neck, trunk and extremities, but the mucous membranesremained clear. All lesions were uniform maculeswithout erythema.Results of the laboratory studiesindicated a normal hemogram and a normal corticosteroidendocrinesystem.Histological examination showed pigment incontinence with melanophagesand a mild perivascular chronic inflammatory infiltrate in the upper dermis (Fig. 2). Montana-Massonstaining showed that the hyperpigmented area had melanin present in both the basal areaand the upper dermis.A diagnosisof PMM was made.
x Correspondmgauthor
PIZ SO926-9959(96)00040-2
Fig. 1. Numerous,well demarcated,oval and roandish. brown and bluish gray maculesand patcheson the trunk.