When I stopped looking only at my skin, the gut became part of the picture.

When I was trying to understand why palmoplantar pustulosis had appeared in my life, I kept coming back to the same question: what was happening beneath the skin?

That question changed the direction of my recovery. Instead of thinking only about creams and the pustules I could see, I began looking at the immune system, food, digestion, stress, nutrient status, antibiotics and the health of my gut.

Gut health was not the only thing I changed. But it became one of the foundations of the way I approached PPP, and I still consider it an important part of my health today.

What are researchers finding about the microbiome and inflammatory skin disease?

Research into the microbiome of people with PPP is still developing, but it has already produced some interesting findings. One study found differences in the oral microbiota of people with palmoplantar pustulosis compared with healthy controls, including lower levels of some Neisseria species.

The gut itself has been studied more extensively in psoriasis. Human studies have reported differences in gut microbial composition between people with psoriasis and healthy controls.

PPP is not identical to plaque psoriasis, so I would not simply transfer every finding from one condition to the other. But the growing research into the gut-skin connection gives us another reason to look beyond the visible skin.

You do not need a cupboard full of supplements to begin.

If I were starting again today, I would still begin with food and everyday habits before making gut health complicated.

Supporting the microbiome does not mean eating every food.

This is important because people often hear “microbiome diversity” and assume that the answer is simply to eat as many different foods as possible. That was not how I approached my own recovery.

I used an elimination phase because I needed to identify my personal triggers. Gluten was the strongest one for me. I also removed refined sugar, dairy, alcohol and highly processed foods during the initial phase.

The goal was to simplify the picture, give my body the best conditions I could, and then understand which foods I could reintroduce and which continued to cause problems for me.

I did not reach remission by chasing one miracle food or one supplement. I changed the environment I was giving my body, day after day, until healthier choices became my normal way of living.

Continue exploring the wider PPP picture.

So, how rare is palmoplantar pustulosis?

The short answer is: PPP is uncommon, but there is no single prevalence number that applies everywhere.

Large population studies have produced estimates ranging from around 5 cases per 100,000 people in Denmark to around 120 per 100,000 in Japan. A Swedish national register study produced an even higher point-prevalence estimate of 147 per 100,000, although its annual prevalence estimate for 2015 was much lower at 26 per 100,000.

What the major population studies actually found.

The numbers below are not perfectly interchangeable. Some studies measure one-year prevalence, others measure point prevalence, and the databases use different definitions of what counts as a PPP case. That difference matters.

Even the word “rare” needs some context.

In the European Union, a disease is generally defined as rare when it affects fewer than 5 in 10,000 people, which is the same as 50 per 100,000.

Some PPP estimates fall well below that threshold. Denmark, the United States, England and Sweden's annual-prevalence estimate all do. Other estimates, such as Germany, Japan and the Swedish base-case point prevalence, are above it.

Five reasons two PPP studies can produce very different numbers.

When I was diagnosed, PPP felt much rarer than any statistic.

I remember how alone I felt. I had never heard of palmoplantar pustulosis. People around me had never heard of it. Even getting the correct diagnosis had not been straightforward.

Years later, after hearing from people with PPP all over the world, I see the statistics differently. Yes, this is an uncommon disease. But uncommon does not mean that you are the only person going through it.

Rare enough to feel lonely does not mean rare enough to be alone.

Do not let the word “rare” make you feel powerless.

Rarity can make a diagnosis frightening because information is harder to find and the person sitting next to you may never have heard of PPP. But there is research, there are dermatologists who know the disease, and there is a worldwide community of people learning from their own experiences.

Start by understanding what PPP is, make sure the diagnosis fits, learn about the known risk factors and treatment options, and then begin paying attention to the patterns in your own body and life.

Palmoplantar pustulosis prevalence FAQ.

If PPP is new to you, continue here.

From spreading pustules and panic attacks to clear skin and a completely different way of living.

Michelle's palmoplantar pustulosis affected both her hands and feet. It frightened her, disrupted her digestion and left her feeling that she had been handed a lifelong condition with very few answers.

Then she started looking beyond the skin. She changed her diet, followed the Autoimmune Protocol, worked on digestive health, adjusted her approach when progress stalled and gradually found a way of living that worked for her.

Her approach went far beyond simply removing one food.

Michelle chose a natural route, but this is her personal treatment story.

In the original interview, Michelle explained that she was frightened by the treatment options being discussed with her and chose not to use biologics. She instead focused on diet, digestive health and lifestyle.

I think it is important to preserve that part of her story without turning it into a universal instruction. Treatment decisions are personal, and today's PPP treatment landscape is not exactly the same as it was when Michelle was diagnosed.

Recovery stories matter because they expand what feels possible. Michelle's path was her own, but hope is something we can share.

Michelle is not the only person who found a path forward.

This was not a mild skin problem.

Sophie told me that the disease had spread across her hands and feet and involved her nails. She had also developed psoriasis elsewhere on her body. Her dermatologist described her case as exceptionally severe.

Within weeks, Sophie began getting her life back.

By February 20, 2019, Sophie told me her skin was not yet perfect but was dramatically better than it had been. Most importantly, she could walk normally again.

When she sent me her longer update in March, she reported that her skin had been in remission for roughly seven weeks. She was deeply grateful to her dermatologist, to the people who had supported her and to herself for continuing when things had felt unbearable.

What I would explain differently today.

The original 2019 article described biologics as medications that simply weaken the immune system. That is too broad. Modern biologic drugs are designed to target specific parts of immune signalling. Secukinumab, for example, targets the inflammatory cytokine IL-17A.

That targeted action does not mean the drugs are free from risk. Current prescribing information for secukinumab includes a warning about infections, including serious infections, and clinicians are advised to use caution in people with chronic or recurrent infections.

Secukinumab has also been studied specifically in moderate-to-severe PPP. In the 2PRECISE trial the primary endpoint was not met at week 16, although the higher-dose group showed more PPPASI75 responses than placebo and some patients continued to improve during longer treatment.

Sophie's recovery was about much more than clear skin.

The most powerful part of Sophie's story is not that she found one perfect treatment. It is that she kept going long enough to find a combination that gave her life back.

Continue from here.

PPP appeared when Janine was 46.

Janine said the first symptoms appeared in 2013 on the bottom of her right foot. She also had a rash on her right elbow and pain in her thumb and other joints. At first she had no idea what was happening.

In the summer of 2014 she began searching online using simple symptom descriptions. One of those searches eventually brought her to my blog.

Janine reached remission without changing everything.

This is an interesting part of her story. Janine said openly that she had not stopped smoking, even though she wanted to eventually.

That should not be interpreted as evidence that smoking does not matter in PPP. Research consistently identifies smoking as one of the strongest modifiable factors associated with palmoplantar pustulosis.

For me, it illustrates something else: recovery stories are individual. One person can improve dramatically while one recognised risk factor remains present. That does not erase the population-level evidence, and it does not mean another person will respond in the same way.

“The fact that I now control it, and it no longer controls me.”

That was the heart of Janine's message. She reported that the pustules, rashes and joint pain were gone. But emotionally, the biggest change was the feeling that PPP no longer dictated what her life looked like.

She also understood remission as something worth protecting. She continued paying attention to stress, food and the routines that she believed had helped her.

A recovery story does not need to be a universal formula to matter. Sometimes its greatest value is showing the person who is suffering that another outcome is possible.

Continue from here.

My finger joint started hurting not long after my PPP diagnosis.

During the period when my PPP was active, I developed pain in the joint of my left index finger. I also had stiffness and clicking in my jaw. At first I assumed the finger pain came from typing, cleaning or simply overusing my hands.

At that point I was dealing with so many other symptoms that the joint pain was something I simply tolerated. My hands and feet were painful, I had recurring throat problems and other inflammatory symptoms, and I was focused primarily on trying to understand what was happening to my skin.

PPP can be connected to more than one type of inflammatory joint disease.

There is no single blood test that explains every form of PPP-related joint pain.

Assessment begins with the pattern of symptoms: which joints hurt, whether there is swelling, how long morning stiffness lasts, whether the spine or chest wall is involved and whether symptoms move together with skin activity.

For persistent inflammatory symptoms, a rheumatology assessment can be especially useful because the skin diagnosis and the joint diagnosis are not always the same disease.

Clearer skin does not automatically mean the joints are fine, and vice versa.

This is another reason I would not advise someone with persistent joint symptoms to simply wait for their PPP to improve. In PAO and SAPHO, bone and joint inflammation can have its own course. In psoriatic arthritis, early recognition matters because ongoing inflammation can damage joints over time.

Lifestyle can still be part of the wider health picture, but inflammatory arthritis deserves an accurate diagnosis so that you know what you are actually dealing with.

PPP happens on the skin, but that does not mean the skin is the only part of the body worth listening to.

PPP and arthritis FAQ.

Continue exploring PPP.

I stopped asking only, “What can I put on my skin?”

For a long time, almost every conversation about my PPP centred on the skin. Creams. Ointments. Steroids. The next product to try. The next attempt to calm what I could see on my hands and feet.

Eventually I began asking a different question: what was happening in the rest of my body, and what could I change?

That question changed the direction of my recovery. I began looking at food, digestion, stress, nutrient status, smoking and alcohol, sleep, movement and the patterns that seemed to precede my own flares.

PPP is not completely disconnected from the rest of your health.

Research does not prove that my personal seven-step framework will put every person with PPP into remission. But it does support something important: PPP is influenced by factors beyond the visible skin.

The seven foundations that became my natural healing plan.

These are not seven isolated tricks. They worked together. Some were directly about things I had identified as personal triggers. Others were about rebuilding the basic conditions my body needed in order to function well.

Using medical treatment does not cancel natural healing.

If your skin is so painful that you cannot walk, sleep or use your hands, symptom relief matters. If you have an infection, joint inflammation or another medical problem, it deserves appropriate treatment. If medication is helping you function, I do not see that as failure.

What I question is the idea that medication has to be the only conversation. You can treat inflammation medically and still ask what you can change in your food, smoking, stress, sleep, movement and overall health.

It is not a supplement cupboard. It is a different way of living.

For me, natural healing means creating a daily environment that supports health instead of repeatedly asking my body to recover from the same things.

It means learning to cook. Reading labels. Saying no sometimes. Going to bed. Moving your body. Looking at what happens after certain foods. Recognising when stress is becoming physical. Correcting a deficiency instead of blindly taking twenty supplements. Getting help when something genuinely needs medical attention.

The goal is not to become perfect. The goal is to create fewer reasons for your body to struggle and more conditions in which it can recover.

A chronic diagnosis tells you the name of the disease. It does not tell you that nothing in your health can change.

Natural healing and PPP FAQ.

Explore each part of the framework.

PPP can get inside your head as well as under your skin.

Pain. Itching. Burning. Not being able to walk properly. Hiding your hands. Cancelling plans. Wondering whether the next treatment will work. Trying to explain a rare disease to people who have never heard of it.

It is not difficult to understand why PPP can affect your mood. For me, one of the hardest parts was feeling that nobody around me truly understood what I was going through.

If PPP has made you feel low, anxious, angry, isolated or frightened about the future, you are far from the only person who has felt that way.

Research now reflects what many people with PPP have been saying for years.

A large study using health insurance claims and electronic health records in the United States and Japan found both anxiety and depressive disorders among people with PPP. The recorded rates varied substantially between databases and countries, which means there is no single percentage that describes every PPP population.

An older controlled study also found moderate-to-severe anxiety to be significantly higher among patients with PPP than matched controls, adding to the evidence that psychological stress and PPP can interact.

It is rarely just one thing.

Find people who do not need PPP explained to them.

Years ago I found an online patient forum and suddenly realised there were other people describing exactly the things I was experiencing. That was enormously comforting.

Later, our own global PPP support community grew into a place where people from different countries could compare experiences, ask the questions that are difficult to answer elsewhere and simply say, “I am having a terrible day,” to people who understand why.

Mental wellbeing improved when I stopped feeling completely powerless.

You do not have to wait until you are at breaking point to ask for help.

There is a difference between having a terrible day because your skin hurts and experiencing persistent depression. Current clinical guidance advises seeking help when depressive symptoms are present for most of the day, nearly every day, for around two weeks or more, particularly when they affect everyday life.

Depression can be treated. Depending on severity and individual circumstances, treatment can include guided self-help, psychological therapies and medication. Having PPP does not make you less deserving of proper mental-health care.

Sometimes you have to explain the impact, not just the rash.

PPP can look relatively small to someone who sees only the percentage of skin involved. If you need support from family, friends, an employer or a doctor, it can help to describe what the disease actually prevents you from doing.

One of the most powerful things another person with PPP can give you is the sentence: “I know exactly what you mean.”

PPP, depression and mental health FAQ.

More support for the difficult days.

The PPP pain relief trick I wish someone had told me about sooner.

I am not going to tell you to moisturise more, wear comfortable shoes or avoid soap. If you have severe PPP, you have probably heard all of that already.

What I needed during my worst flare was much more basic: something that would stop the deep cracks in my foot from hurting every single time I moved.

Every step felt like walking on broken glass.

At the peak of my PPP flare-ups, the pain was unbearable. My feet were cracked deeply enough that putting weight on them caused sharp pain, and sometimes even moving my foot without standing on it hurt because the fissures pulled apart.

The itching and burning were relentless too. Prescription creams never gave me the kind of immediate relief I needed. I was desperate for something that could make the skin hurt less so that I could walk, shower and function normally.

That is the problem DuoDERM solved for me.

It does not need to treat PPP itself to make a cracked foot hurt much less.

DuoDERM forms a soft gel when the hydrocolloid material meets moisture from a wound. According to Convatec, the dressing creates a moist wound environment, provides mechanical protection and keeps exposed nerve endings moist, which can help relieve discomfort.

The dressing can turn whitish or yellow underneath. That does not automatically mean pus.

When hydrocolloid absorbs moisture it forms a gel. Chelsea and Westminster Hospital specifically warns patients that DuoDERM can develop a yellow-looking gel and an odour, neither of which automatically means the wound is infected.

That is useful to know the first time you peel one off. You still need to watch the skin itself for signs of infection, but the appearance of the gel alone can be normal.

DuoDERM is the brand I used. Hydrocolloid is the important word to remember.

DuoDERM happened to be what my dermatologist gave me, and because it worked so well I continued using it. But it belongs to a wider category of hydrocolloid wound dressings.

If DuoDERM is difficult to find where you live, ask a pharmacy for a sterile hydrocolloid wound dressing suitable for a lightly exuding fissure. You need a piece large enough to extend beyond the crack so it can adhere to intact skin.

Think painful fissure, not entire palm or sole.

NHS wound guidance advises against hydrocolloid wafer dressings on infected or heavily exuding wounds and does not recommend them for diabetic foot wounds because they are occlusive.

DuoDERM did not heal the reason I had PPP. It did something I desperately needed at the time: it stopped every step from hurting.

This is why I keep sharing this tip.

A reader named Marilyn later left a comment under this article saying her experience with hydrocolloid bandages was essentially identical to mine. She said they enabled her to walk and work again.

That is exactly why this article exists. It is a small piece of practical knowledge that can make a very big difference when PPP is at its worst.

DuoDERM and PPP pain relief FAQ.

When you are ready for the next step.

More than nine appointments, several diagnoses and one very confused patient.

My first signs were tiny pin-sized red dots on the sole of my right foot. There were perhaps ten or fifteen of them. For the first couple of months they did not look dramatic. Gradually the area became itchy, but there were still no obvious pustules and I had not noticed anything significant on my hands.

The symptoms had appeared during the months after I had taken antibiotics for an infection around a wisdom tooth. I later came to regard antibiotics and infections as relevant parts of my own health history, but the timing alone cannot tell us what caused my PPP.

Then one morning the picture changed completely. I woke with an eruption involving my foot and hand but also areas of my thighs, buttocks and genital region. At the emergency department, several possibilities were discussed, including herpes, hand-foot-and-mouth disease and eventually scabies.

My family and I were treated for scabies, but my symptoms did not go away. At other appointments I was told that my shoes might be responsible for the blisters on my feet, which did not explain what was happening to my hand.

Eventually I reached the right diagnosis. But by then I had learned how frightening it is to know that something is wrong with your body while nobody seems able to give it a name.

Five features that are typical of palmoplantar pustulosis.

None of these features proves the diagnosis by itself. Together, however, they create a pattern that should make PPP worth considering.

What can palmoplantar pustulosis be mistaken for?

PPP and pompholyx can look similar even under the microscope.

A 2013 study compared biopsies from 40 patients with PPP and 35 with pompholyx. The researchers identified several microscopic features that favoured PPP, but they also emphasised that the two diseases share both clinical and histological features.

A later 2019 study was designed specifically to identify additional histological clues that could separate PPP from pompholyx. The fact that researchers continue to study this distinction tells us something important: a difficult case can be genuinely difficult, even for dermatologists and pathologists.

They look like pus-filled spots, but PPP pustules are sterile.

The yellow-white appearance understandably makes people think of bacterial infection. In PPP, however, the characteristic pustules are sterile. The fluid contains inflammatory cells rather than being a bacterial abscess.

That does not mean PPP skin can never become infected. Deep fissures and damaged skin can develop a secondary infection, which is a different problem and may need treatment.

PPP itself is not contagious.

If the diagnosis is still uncertain, these are reasonable questions.

You do not need to diagnose yourself. But you are allowed to arrive informed, ask good questions and say when a diagnosis does not explain what you are experiencing.

A diagnosis gives the problem a name. Then the real questions begin.

When I finally knew I had PPP, I was relieved to have an explanation. But I quickly discovered that knowing the name did not answer the questions that mattered most to me: Why had this happened? What made my flares worse? What could I change? Was long-term remission possible?

Those questions eventually changed the direction of my life. I began researching possible triggers, diet, stress, gut health, nutrient status and the wider factors that became part of my own recovery.

Getting the right diagnosis mattered. Refusing to believe that the diagnosis was the end of the story mattered too.

Palmoplantar pustulosis diagnosis FAQ.

If you are still trying to understand what you are looking at.

I was living in a state of stress that had started to feel normal.

Around the time I developed PPP, I was working full-time in an extremely stressful and negative environment while also raising a toddler. I was sleeping badly and felt permanently overwhelmed.

I remember waking in the morning with my pulse racing and feeling frightened about what the working day would bring. Looking back, those were not subtle signs. My body was telling me that the situation was not sustainable, and I kept going anyway.

There were other things happening at the same time. I was not eating particularly well, I had experienced repeated throat infections and had taken several courses of antibiotics. I cannot separate those factors after the event or claim that one of them caused the disease.

The evidence is limited, but stress has not disappeared from the PPP conversation.

PPP has never had a large body of stress-specific research. One of the best-known studies is still a small controlled study published in 2002. The researchers found significantly higher anxiety levels in people with PPP than in matched controls and concluded that stress could be related to worsening of the disease.

That study cannot tell us that stress causes PPP. Anxiety can also be a consequence of living with a painful, unpredictable skin disease. This is one of the difficulties when studying the relationship.

Sometimes stress comes first. Sometimes PPP creates the stress. Often the two feed each other.

This is why I do not see stress management as an optional wellness extra. If stress is one of your personal triggers, breaking this cycle can be a genuine part of managing PPP.

I needed both less stress and better ways to recover from the stress I could not remove.

Sometimes the stressful thing is not optional.

You cannot meditate away bereavement. You may not be able to leave a job tomorrow. You cannot simply stop caring for somebody who needs you. Financial pressure does not disappear because somebody tells you to practise mindfulness.

In those periods, I would stop thinking in terms of eliminating stress and think instead about reducing the total load and increasing recovery. One unnecessary commitment removed. One person asked for help. One earlier night. Ten quiet minutes. A walk. A conversation. A boundary.

Small reductions in pressure still count when the big problem cannot be solved today.

I learned to see the first signs of a stress flare not as proof that I was back at the beginning, but as my body's early warning system.

Stress and PPP FAQ.

Continue exploring the bigger PPP picture.

Nobody treating my PPP had asked me what I was eating.

My medical appointments were understandably focused on the skin in front of them. I was prescribed topical treatments and was told about medical options, but food, digestion and lifestyle were not part of the conversation.

By that point I had reached the stage where I wanted to understand everything I could potentially influence. I had already begun looking beyond the visible rash at stress, antibiotics, infections, gut health and the wider state of my body. Food became the most obvious thing I was exposing myself to every single day.

Gluten became my strongest individual dietary trigger.

Gluten was the first major food group I removed. Soon after making the change, my skin actually flared. At the time I interpreted that as my body adjusting to the new diet.

Today I would phrase that more carefully. I know the flare happened after I stopped eating gluten, but I cannot know what caused that short-term worsening. PPP naturally waxed and waned, and I was changing several things in my life during the same period.

What mattered was what happened over the following weeks. I stayed consistent. The flare settled. The pattern of new pustules began to change, and eventually gluten became one of the foods for which I noticed the clearest repeatable relationship with my own symptoms.

Mostly simple food that looked like food.

Once I stopped building meals around bread, pasta and convenience foods, the question became surprisingly simple: what could I put on the plate that was nutrient-dense, minimally processed and made me feel well?

Gluten stood out most strongly, but it was not the only change.

I was not looking for one good day. I was looking for the pattern to change.

PPP naturally goes through better and worse periods, so I did not want to mistake one quiet week for proof that I had found the answer. I kept going and watched what happened to the cycles.

I began seeing fewer new pustules. The outbreaks became less aggressive. The skin had more time to heal between cycles. Other parts of my health were changing too, and the direction felt different from the endless flare-after-flare pattern I had been trapped in.

Diet was not the only thing I changed. I was also working on stress, digestion, sleep, nutrients and the wider lifestyle framework I have described throughout Well-Healed.

I still think the gut matters. I just explain it differently now.

When I first began writing about PPP, I sometimes described a damaged or “leaky” gut as if it were the established underlying cause of the disease. PPP research does not allow us to say that.

My view of digestive health itself has not become less important. The gut is a major immune interface, nutrition depends on digestion and absorption, and my own digestive health changed during the same period that I rebuilt my diet.

I do not need one unproven gut theory to explain every case of PPP in order to believe that looking after digestion and eating nourishing food are worthwhile parts of a whole-health approach.

The research is smaller than I wish it were, but diet has been studied directly in PPP.

A 2011 review of PPP management also highlighted gluten sensitivity as potentially important in selected patients. That wording still feels right to me: selected patients. The useful question is not whether every person with PPP must eat exactly as I did. It is whether food is one of the modifiable pieces worth investigating in your own case.

Start simple. Stay consistent. Pay attention.

I did not change my diet because food had become my enemy. I changed it because food was one of the most powerful things I could choose for my health every day.

My PPP diet FAQ.

The other pieces of my PPP recovery.