PLANTAR PUSTULOSIS

Krista Switzer SUNY IT 3/18/13

Patient: Paula T.

Age 57

Subjective CC: rash on sole of left foot HPI: This is a 57 year old female who came in to the office with a rash on the sole of her left foot. It has come and gone for the past year. She gets episodes and she has been seen in the office here in the past. She states the rash itches and burns. In the beginning she tried to use otc hydrocortisone cream without any relief. The last time she was seen for this was 6 months ago and she was given betamethasone cream to use BID for 2 weeks. She said that it helped but never completely went away. She has not noticed a time of year when it is worse or better. She has noticed that when she is on her feet running errands during busy times, it flares up and gets much worse. Nothing has ever completely taken it away, just made it more tolerable.

Review of systems
Const: No fevers, acute distress, fatigue, weight loss or gain. Ears: No pain, tinnitus, hearing loss, vertigo. Neck: No swollen glands, no pain or stiffness. Nose: No recent colds, nasal congestion, post nasal drip, sinus pain. Mouth: No sore throats, change in voice, odor, dryness. CV: No chest pain, palpitations, heart murmur. Resp: No shortness of breath, no cough or wheezing. GI: No nausea, vomiting, diarrhea, constipation or abdominal pain. Musculo: No joint pain, swelling, discoloration, stiffness. Neuro: No numbness, tingling, weakness. Skin: Rash on sole of left foot with itching and burning. Dark redness at the base of rash. Surrounding skin warm to touch. No hair loss, abnormal moles or lesions. Hema/lymph: No abnormal bruising or bleeding.

Past Medical History

Iron deficiency anemia Obesity Menopausal status Previous tobacco use
Urinary incontinence Herpes simplex type 1 Right shoulder tendonitis

PMH
Immunizations Flu 10/2012 Pneumovax 10/2012 Zostavax-never Adacel 2009 Hep B series completed 2001 Current Medications Multivitamin with Iron Allergies NKDA No food or seasonal allergies Surgical history C-section x 2 (1993 & 1990)

Social and Family history

Pt is married G2P2 Previous smoker 1ppd x 20 years Quit 2003 Consumes 1 glass of wine with dinner each night Never used illicit drugs Drinks 1-2 cups of coffee every day Mother-psoriasis, HTN Father- HTN, hyperlipidemia Maternal GM- breast CA Maternal GF- unknown Paternal GM- HTN Paternal GF- diabetes

Health Status: Generally healthy, keeps up routine health maintenance. At risk for HTN due to family history so regular screening important.

Objective
Vitals BP 126/78 P 62 R 14 T 97.9 Wt 146# Ht 66 BMI 23.6

Exam
Const: Pt is a healthy and well developed 57 year old female who is alert, cooperative and in no acute distress. Head: Atraumatic and normocephalic ENMT: Tympanic membranes grey in color and intact. Cone of light seen bilaterally. Nares: patent and pink, moist. Oropharynx: moist, no redness or erythema. Neck: No adenopathy or thyromegaly Resp: Clear lungs, no wheezes, rales or rhonchi CV: Regular, rate and rhythm, no heart murmurs, clicks or rubs GI: Soft, nontender, bowel sounds active every 3 seconds, no hepatosplenomegaly Extremities: No clubbing, cyanosis or edema. Dorsalis pedis and posterior tibialis pulses 2+ bilaterally Lymph: No supraclavicular, axillary or inguinal nodes Neuro: sensation to light touch intact bilateral lower extremities, deep tendon reflexes in lower extremities equal bilaterally Musculo: Full range of motion ankles and feet. No tenderness to joints lower extremities Skin: deep red, dusky papular rash with pustules on an erythematous base to left central sole. Area about 2 in x 1 in.

Assessment: Plantar pustulosis (skin disorder, other 709.8)

Differential Diagnosis
Erythema Nodosum Erythroderma Bullous Pemphigold Toxic Epidermal Necrosis Vasculitis

Diagnostics
Diagnosis is based on appearance of characteristic dark red rash with pustules. Lab work done to rule out other etiologies, non specific such as: CBC CMP Free T4 TSH ANA (autoimmune disease marker) ESR (inflammatory marker) Rheumatoid factor (Pt had all normal labs work when initially diagnosed.

Plan
Rest affected area while inflamed as much as possible Use thick emollient to soften dry skin to prevent fissures Soak in warm water with emulsifying ointment for 10 minutes a day Topical steroids are agents which range in potency and vehicle. Only the strongest ones are effective in conditions that affect the hands and the feet. Alternative therapy: Coal tar treatment- a black viscous liquid made from distilled coal Oral med: Acitretin is an oral retinoid used to treat severe psoriasis. Paula had tried mild steroids without relief in past. We prescribed Lidex Cream 0.05%. Apply BID x 7 days. Keep area covered for 7 days after medication treatment.

Clinical Features and Treatment

This rash looks like crops of sterile pustules occurring on one or both hands and feet. They are associated with thickened, scaly red skin which easily develops painful cracks and fissures. May persist for years and varies in severity. Not infectious to other people and does not interfere with your general health. The discomfort can be considerable, interfering with work and leisure activities. Walking can cause it to exacerbate Treatment does not always cure. It may take several months to improve. Advise patient to use comfortable footwear to avoid friction and minor injuries. Cover deep fissures with a waterproof dressing.

Etiology
The cause is unknown. It appears to be a disorder of eccrine sweat glands, which are numerous on the palms and soles. It is probably autoimmune in origin as there is an association with other autoimmune diseases such as celiac disease, thyroid disease and diabetes. Palmoplantar pustulosis was previously considered a localized form of pustular psoriasis but about 10-20% of patients with this disease have psoriasis elsewhere. This is more common in women. Rarely occurs before adulthood. There is thought there may be a genetic component. More common in smokers or previous smokers because activated nicotine receptors in the sweat glands cause an inflammatory process.

More pictures

References
http://www.aocd.org/skin/dermatologic_diseases/palmoplantar_pu stu.html http://www.skincell.org/index.php/skin-conditions/ppp http://psoriasis.dermnetnz.org/scaly/palmoplantar-pustulosis.html