Why is it so difficult to diagnose Palmoplantar Pustulosis?

10/3/2015

Before I got my PPP diagnosis I had been to over 9 doctor appointments where one of them was a trip to the ER where I was diagnosed with having scabies. Another doctor persisted it was my shoes causing the blisters, and ignoring me when I said it doesn't explain the blisters on my hand?

My onset of PPP started after I had taken a course of antibiotics due to a gum infection around my wisdom tooth. It took several months before developing in to a full on PPP outbreak. It started of with approx 10-15 red pin sized red dots on the sole of my right foot. In the first couple of months it stayed like that, just a few red dots. Gradually my foot started to become itchy as well but there were no blisters. I had no symptoms on my hand as far as I was aware of. My foot actually didn't bother me too much even though I was a bit concerned.

One morning a few months after first noticing the red pin sized dots I woke up with an outbreak of skin bumps and blisters all over my inner thighs, bum, genital area and my foot and hand. It was so soar and itchy at the same time. I made it to the ER where they first thought it was herpes but quickly changed their mind and decided it was the foot and mouth disease, to go on and change their mind again (after a quick google on the Internet) and confirmed it was scabies.

In hindsight I can understand the difficulty they had to diagnose it was PPP as Palmoplantar Pustulosis is only localised to the hand and foot, but it was definitely wrong of the doctor to confirm it was scabies without even seeing any evidence of scabies under my skin. The weeks following my ER visit was horrendous and depressing. The whole family was wrongly treated for scabies but mine wouldn't go away for obvious reasons.

In palmoplantar pustulosis, the pustules only occur on the hands and feet. The skin under and around the pustules is red. The blisters tend to occur in cycles over a period of days or weeks. The reason why this chronic skin condition is so difficult to diagnose is simply down to the disease is so unusual and a lot of doctors have not heard of PPP nor met a patient with PPP before and therefore gets another diagnosis such an allergy or another skin condition. If you suspect you have PPP please book an appointment with your dermatologist to get it confirmed. They will do a laboratory test to make sure there are no bacterial infection. PPP blisters are sterile and not contagious.

Here's 5 symptoms of Palmoplantar Pustulosis.

1. Before the blisters become actually blisters on the sole of your foot they start of as red pin sized dots. Once the PPP outbreak has been established they turn in to tiny liquid filled blisters. The area normally spread and becomes larger and larger.

2. On the hand the outbreaks normally starts off with an area of dry skin. If you look closely you can see tiny transparent blisters forming under the skin on the palm of your hand.

3. Both the hand and feet becomes very itchy and red.

4. The above symptoms often occur after a course of antibiotics or other medical intervention or a trauma to the skin.

5. The blisters usually fill with a small amount of pus when they mature and turn brown, then scaly. The scaling may be so prominent that only redness, blood and scaling is seen.

Do consider reading my book where I write more on the subject.

Please share with me how you were first diagnosed and how you noticed your first symptoms, I would love to hear from you.

Åsa Kärrman

A foot covered in a PPP outbreak. Photo in courtesy of Dr. Gary M. White, MD from ww.regionalderm.com

A hand covered in a PPP outbreak. Photo in courtesy of Dr. Gary M. White, MD from ww.regionalderm.com

18 Comments

Kay Fallon link

9/6/2016 10:19:31 pm

Hey Asa, so sorry you had so much trouble getting a diagnosis. And thank you for your post.

One day I had a pustule on the palm of one hand. I popped it and it went away. A few weeks later I woke up with tender, itchy soles of both feet. When I looked at them, they were completely covered in little red dots like on your photos. It was summer and I went barefoot a lot, so I thought I had stepped in something.

I made an appointment with my primary care doctor and was seen the next day. By then, I had white pustules on my palms as well. I got referred to dermatology and was misdiagnosed with exzema and prescribed coal tar shampoo to soaky feet in. That made it way worse and couldn't even walk for a few days.

My next appointment with derm included a biopsy that indicated palmoplantar pustulosis. Thus began years of numerous different treatments, typically and orally. Nothing really worked though.

About 5 years ago, I stopped getting pustules. I hadn't been using medications of any kind. But I did develope psoriatic arthritis. I would opt for pustules over PsA any day! If you have sore, stiff, swollen joints, please see a rheumatologist!

During the last 5 years without pustules, I still have extremely fast growing skin on palms and sales. There is a very noticeable cutoff line on outside of Palms that goes around entire hands and fingers, and most of sales of feet. The skin becomes quite thick, dried, splits and peeks off. This requires me to tend to it daily and takes 2 hours each day. That is, until 3 weeks ago when it just stopped growing.

Do I trust it not to come back? No! Lol. My feet don't look as good as my hands, but feet ate easy to hide. The once bright red palms have faded to light pink. I have no idea what put me in remission but trying to savor it. Wish PsA would go away too. Forever!

I can't think of anything that might have triggered onset of PPP, other than stress. Currently I have very little stress and have taken up yoga for pain. Yoga helps me a lot. I have no idea why my PPP is in remission, as I stopped taking meds for it and only use eucerin cream to keep hands moisturized. I've been on a biologic for PsA for 3 years and don't think it had any effect on PPP, since pustules stopped 5 years ago and nothing changed until recently.

Hope this is what you were looking for in some way. Feel free to ask me questions. And I wish you success in putting your PPP in remission. I am going to speak with a drug company about my PPP. Hopefully they can target the IL cells for our type of p.

Kay

Well Healed link

9/27/2016 07:55:32 pm

Hi Kay

Thank you very much for your comment and for finding my website.

I don’t know if you read my other blog posts, but if you do, you will find out I agree with you that stress is one of the major triggers to onset PPP.

Luckily I’ve been cleared from Palmoplantar Pustular Psoriasis for the last 4,5 years now as well as other health issues that comes with disease. In my book “How To Treat PPP Naturally” I write about how I healed from PPP by changing my life style around as well as my diet. The important lesson is to understand how come and why you got sick in the first place, and what steps to take to get well again.

I have also written a blog post about the connection between PPP and RA (PSA) which you might find interesting to read. Link below:

http://www.well-healed.com/blog/palmoplantar-pustulosis-and-arthritis

I wish you the best of health,

Åsa

Doris Brother

2/28/2017 07:03:42 pm

I was also told that my foot and hand pustules were possibly due to scabies and was prescribed medicine for this. After finally determining that I had Palmoplantar Pustulosis and after suffering from it for a few years, it got so bad that I could hardly walk very far due to the pain. I then began to think deeply about how to treat PPP after using ointments, etc. that did not work. I found that if the pustule was popped with a sterile needle and the liquid auto-immune cells were drained, that it would then immediately go into a healing state. It worked and I found that treating the area with non-alcohol lotion during this time that it would heal so much faster. I had previously taken an anti-histamine to dry these pustules up and it seemed to work too. However, it wasn't until I drained the white pustules themselves that I had immediate relief from pain when walking and that the action of healing took place. I have been PPP free for years now.

Åsa link

3/5/2017 07:15:01 pm

Hi Doris,

That is very interesting, thanks so much for sharing your story.
Just like you….. I used to pop my pustules with a sterile needle......but for me it didn't clear the outbreaks but made them less itchy.
I’m curious if popping the blisters were the only thing you did at the time to get in to remission?

I’m very happy to hear you’ve been cleared and free from palmoplantar pustular psoriasis for years now, keep up the good work 

All the best,

Åsa

Kat

9/15/2016 09:46:18 pm

Hello,

I have yet to be Doctor diagnosed...but I am a nurse and have been researching...after one wound doc called it ring worm then the next week something else. Looking at pics on the internet day after day then I came across your picture and thought...how did they get a pic of MY foot? I go to my PCP Oct. 3rd again....presented this in MAY have been back and forth...now going with ammo...lol. Dont see the dermatologist until Nov...I can only imagine how it would feel if I didnt already have neuropathy. Good luck to you!

Kat

Well Healed link

9/27/2016 08:26:05 pm

Hi Kat,

Thank you for your comment!!

Best of luck at the dermatologist in November, hang in there. There's nothing more frustrating to keep getting the wrong diagnosis. I sincerely hope you don't have PPP, but do go there informed and prepared (ammo) and show them the pictures from this blog post. I went through hell before I was rightly diagnosed and could deal with the health issue accordingly.

I hope you will get some relief soon,

I'm wishing you the best of health!!

Åsa x

3/30/2017 09:34:49 am

I recently have been diagnosed, both self and emergency room. I began seeing bumps on my hands and feet a few years ago, but they were not bad and I believed it was eczema from too much hand sanitizer (though I couldn't explain my feet). A few months ago my left foot had very thick dry skin on it. I was putting lotions and hydrocortisone cream on it, but it didn't budge. Two weeks ago the neighbor kids passed on their strep throat to me, so I went to the er after four days of pain. I received two penicillin shots and while I was there decided to ask about my foot. I was a bit worried the dr would say it's athlete's foot and sure enough he did. Anyhow, he recommended foot spray and a hand sanitizer w/ moisturizer. I knew very well that this was going to flare it up, but for some reason tried it anyway. Ugh, the next day I had bumps all over my hands and feet. I went back to the er and "helped the dr with the PPP diagnosis. I was given a few meds, but just used the steroid cream a few days. I decided to buy Domesboro soak and Triderma cream, which worked almost instantly in drying up the bubbles. It has been 2 weeks since the outbreak and most of them are dried and falling off. I noticed that my left side was much more affected than my right side. My left foot is cracked and bloody on the side. It is hard to walk unless I soak my feet first. I have been dealing with a lot of stress too as I quit my job a few weeks before the strep. I'm glad I figured out what was going on. It's a little concerning knowing it can occur again at anytime though. I am going to the dermatologist soon to start therapy. The itching drives me crazy!!! For now, I just continue to put on the creams and if it gets too bad I take a hydroxyzine.

Chelseaa

6/11/2018 04:53:19 am

I was diagnosed this year. I’ve had plaque psoriasis my entire life, but I was just recently diagnosed with pustular psoriasis. One day I noticed a small pustule on my hand but chose to ignore. Over the course of a few weeks, a few more popped up on my legs. I was nervous about what it could be so I went to the ER. They told me they thought it was either syphillis or Rocky Mountain Spotted Fever. I was doubtful that it was either of those. I was referred to a dermatologist and I was diagnosed with psoriasis. I was prescribed antibiotics to keep from getting an infection,but the antibiotics made me extremely sick and nauseous. I went off of them and finally started moisturizing every few hours to keep my skin from drying out, cracking, and bleeding. This is a horrible disease. It’s hard to walk, hard to hold things, hard to shower properly. I worry that people will think I have a contagious disease because he lesions are so severe. Hopefully with time I will heal.

Well-Healed Åsa link

6/19/2018 06:34:19 pm

Hi Chelseaa,

Thank you for contacting me and sharing your story.

I'm sorry to hear you are sick. Me too was wrongly diagnosed a good few times before I received the correct diagnosis. PPP is a depressing and a horrible disease 

What you need to do is to improve your immune system. The way to do that is to remove all the things in your life causing damage to yourself and add all the things that is good for you and your immune system. I recommend you have a look and read through my blog post and blog comments to get some inspiration. In my book I write more in detail how the immune system works and what you need to do to heal.

I'm wishing you health and the strength you need to heal.

Kind Regards,

Åsa

Dorothy

6/22/2018 01:55:39 am

Hi Asa
My journey with pop began just over a year ago. The skin on my feet felt burned and split open in many areas when I stood up. Luckily I saw a dermatologist within a couple months who put me on acitretin & steroid creams. A month later I was able to walk my daughter down the aisle. My hands started getting bad this past Spring - they are red & itchy but I have almost callous like bumps in many areas - on the tops of my fingers on the joints & particularly between thumb & forefinger. I quit taking acretetin last November because of side affects but have kept up with soaking & creaming the feet with steroid creams. I do not have RA but my Mom & sister do. I have a couple other auto immune disorders as well.
I am really hoping the small hard lumps aren't the start of RA.
Thanks for your time.
Take care.

3/12/2020 03:48:02 am

About 4 years ago, I developed PPP. At first, there were maybe 4-5 small brown dots on my hands. I worked at a nursing home where I used hand sanitizer constantly... an also showered patients, so my feet were wet a lot. I noticed the bumps on my feet, and figured it was just dermatitis. I switched jobs and began working for the government, which stressed me out a lot emotionally and mentally. After over a year of dealing with my boss belittling me everyday, I decided to quit. I went home and spoke to a neighbor and her child (who had strep throat), an after a few hours my throat was sore. I dealt with strep throat for 4 days before I finally went to the ER. Once there, I also asked about the bumps on my feet and hands and was told it was athletes feet, and to buy this expensive hand sanitizer an anti fungal spray. I received 2 shots of penicillin. The next day my hands and feet were inflamed! I was scared to go back to the dr because of the reaction to their advice. I must have went a few weeks without treatment before I finally diagnosed myself an went back to the ER doctor. After confirming what I knew, I had about 12 doctors checking out my pustulars. I went to the dermatologist, who put me on methotrexate. After a few weeks of taking the chemo pills, my hands and feet had very little bumps left thankfully. I stayed on the chemo for over a year until I went back to my clinic doctor and found out I had liver issues. Still, the doctors here had no clue what type of issues PPP caused. I ended up having diabetes, which I started believing was associated with my liver issues... so I stopped taking the methotrexate and about 6 mos later my diabetes went away. My doctor couldn’t believe it. None of the treatments such as cortisone creams, UV lighting, psoriasis creams etc.. helped me at all. In fact, the steroid creams made my hands worse. The only thing that helped me was the methotrexate, charcoal soaps, and popping them with tweezers. I have not had a severe outbreak in over a year an a half. I do get tiny bumps on my hands and feet from time to time, but maybe only one or two at a time. Now, I just avoid hand sanitizers, harsh chemicals, and stressful situations, an I try to stay away from people who are sick due to my suppressed immune system. I still have a very high white blood cell count. If I had another outbreak, I would not opt to do chemo again.

Åsa - Well-Healed link

3/16/2020 06:51:44 pm

Hi Mo,

Thank you so much for taking the time to share your PPP story, which is similar to mine, I'm glad you are doing better but do try to boost your immune system.

We all have different triggers to onset the PPP outbreaks, mine is stress for sure. My first PPP outbreak was triggered due to a combination of negative stress, a poor diet and antibiotics after several strep throat infections (seven in a row)

Do consider joining our Facebook support group if you haven't already done so. Sometimes is nice to connect with other people in the same situation.
https://www.facebook.com/groups/PalmoplantarPustulosisSupport/

Stay well,

Åsa

Melissa

10/15/2020 02:25:11 am

Hi Asa,

I was wondering if you know of PPP being related to metal implants? My ppp is localised to my right foot and appeared shortly after I had surgery to have a metal rod implanted in my right leg. (Within days). In the seven years I’ve had this rash I have only gone into remission once, for four years when I moved to a colder less humid state. I am so confused. Also, is your book available on audible?

Thank you.

Åsa Kärrman

10/16/2020 11:31:18 am

Hi Melissa,

Thanks for your comment.

There are several studies that show that metal toxicity is one of the causes to trigger autoimmune disease including PPP. The reason is the metal interferes with the microbiome in our gut (the good gut bacteria which is part of our immune system). So if you suspect metal to be one of your triggers to onset PPP, taking a probiotic supplement is crucial.
Unfortunately there's no audio version of my book at the moment, but something I hope to be able to release in a near future :)

All the best,

Åsa

Dusman

11/14/2021 02:53:30 pm

Hi Asa,

Wow, your diagnosis process is very similar to mine. When I was about 17, I was diagnosed with PPP, but it was only after first being misdiagnosed with scabies, just like you! Of course, I put the scabies treatment cream on myself for quite a while, and it didn't work. I felt like a leper and was embarrassed at people seeing my feet and hands. I also assumed I was contagious, so I didn't hold my girlfriend's hand for a long period of time. Eventually, I was properly diagnosed. I was also wrongly diagnosed with hand-foot-mouth disease much later as an adult when I had another flare and that particular flare left small scars on my hands and the bottom of my feet. It's interesting that you note that the pinpoint red dots on the bottom of your feet and the itching are the first tell-tale sign of the beginning of a flare. I too have noted the same thing. I can tell that a PPP flare is coming now even without looking at the bottom of my feet simply due to the itchy/burning feeling. However, I have also noted that if I monitor my stress level, it seems I can stop an ensuring flare in it's tracks. Again, great website!

Åsa Well-Healed

11/14/2021 07:28:09 pm

Thank you Dusman :)

The misdiagnosis of scabies is just heartbreaking. Just like you I had to avoid close contact with people, In the office I had to hang my coat where nobody else hung their coats and jackets just in case the bugs would crawl over to their clothes, it was a crazy time and I felt genuinely depressed, never been that low in my entire lift.

I have since heard from other PPP sufferers who got the scabies diagnose by their doctor as well, so perhaps more common than one might think?

Suzanne

9/8/2022 02:16:15 pm

Hi
I recently developed a rash on the sole of my foot and thought it was tinea. I tried treating it with creams and sprays, only for it to get worse. After nothing helped I went to the doctor. Poor guy took one look and said, I've never seen anything like that, hang on. Next thing he got another doctor in the room who came armed with a magnifying glass. Luckily for me she had seen this before and instantly told me what it was. I burst into tears when she told me it may never go away. I had recently experience quite a bit of stress (my dog died and my son ran away from home -i know, sounds like a country and western song right? 🤣🤣). I'm still treating it with a steroid cream and dealing with quite painful feet. It's also starting to appearing on the palms of my hands too.

After googling the condition, I've realised that at the moment mine isn't too bad, but still painful and embarrassing. I have a family history of arthritis too and have had a lot of joint pain which is becoming worse. I guess I'll just keep treating it and hope for the best.

Thank you everyone for posting your comments here. This has been one of the most helpful sites I've found so far.

I wish everyone good health and thank you.

Dusman

9/8/2022 02:37:05 pm

Hi Suzanne,
Sadly, your story is like many of us. In regards to your joint pain, I would encourage you to get a referral to a good rheumatologist if possible. My joint pain became significant, and eventually, I was diagnosed with psoriatic arthritis. I take Humira once weekly for this, and it controls my joint pain and my PPP. I wish you the best!

Why is it so difficult to diagnose Palmoplantar Pustulosis?

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