Palmoplantar pustulosis
Recurring yellow-white sterile pustules, redness, brown spots, scale and fissures.
A clear visual comparison
Palmoplantar Pustulosis vs Psoriasis
Palmoplantar pustulosis and psoriasis are related inflammatory skin diseases, but PPP is not the same clinical presentation as ordinary plaque psoriasis.
PPP causes recurring sterile pustules mainly on the palms and soles. Plaque psoriasis usually causes sharply defined, raised, scaly plaques and can affect many areas of the body. Palmoplantar psoriasis is plaque psoriasis specifically affecting hands and feet.
Written by Åsa Kärrman · Patient advocate and author · Last updated August 2026
Plaque psoriasis
Raised, well-defined inflammatory plaques with dry scale; pustules are not the main feature.
The direct answer:
PPP and plaque psoriasis share inflammatory pathways and can coexist,
but they differ in their typical lesions, distribution, risk factors,
genetics and response to treatment. Experts do not universally agree
whether PPP should be classified as a form of psoriasis or as a
distinct but related disease.
First, separate the terms
PPP, palmoplantar psoriasis and pustular psoriasis are not interchangeable.
Confusion often begins because several different diagnoses contain the words “palmoplantar”, “pustular” or “psoriasis”.
Palmoplantar pustulosis
A chronic, relapsing eruption of sterile pustules on palms and/or soles, usually with redness, brown macules, scale and fissures.
Palmoplantar psoriasis
Plaque psoriasis affecting palms and soles. Skin is often sharply defined, thickened, dry and cracked; pustules are not necessarily present.
Generalised pustular psoriasis
A rare, potentially serious condition with widespread pustules and systemic inflammation. It is not simply severe PPP.
Side-by-side comparison
Key differences between PPP and plaque psoriasis.
The table describes common patterns. Individual cases can overlap, and diagnosis cannot be made from one feature alone.
| Feature | Palmoplantar pustulosis | Plaque psoriasis |
|---|---|---|
| Main lesion | Recurring sterile yellow-white pustules that dry into brown spots, scale and crusts. | Raised, well-defined inflammatory plaques with dry white or silvery scale. |
| Typical location | Primarily palms and soles. | Commonly elbows, knees, scalp, trunk and lower back, but any skin site can be affected. |
| Hands and feet | The defining location of PPP. | Can affect palms and soles as palmoplantar psoriasis. |
| Pustules | Characteristic. The fluid is typically sterile. | Not typical of ordinary plaque psoriasis. |
| Course | Repeated crops of pustules with overlapping active, drying and peeling phases. | Persistent or recurring plaques that may enlarge, clear or recur. |
| Smoking association | Very strong association; many patients are current or former smokers. | Smoking can worsen psoriasis, but the association is less distinctive than in PPP. |
| Sex pattern | Reported much more often in women, typically beginning in middle adulthood. | Affects all sexes; age of onset varies widely. |
| Genetics | Does not show the same strong association with the major plaque-psoriasis susceptibility locus HLA-Cw6/PSORS1. | HLA-Cw6 is an important risk factor, especially in early-onset plaque psoriasis. |
| Associated musculoskeletal disease | Associated with SAPHO syndrome and related osteoarticular inflammation in some patients. | Associated with psoriatic arthritis. |
| Treatment response | Often difficult to treat and may respond less reliably to biologics effective for plaque psoriasis. | Many well-established topical, phototherapy, systemic and biologic options are available. |
How they look and behave
The difference is more than “pustules versus scale”.
Typical PPP pattern
- Small sterile pustules form in crops
- New and older lesions may appear together
- Pustules can turn yellow-brown as they dry
- Redness, scaling and deep fissures may follow
- Pain can severely affect walking and hand use
- Nail changes can occur
Typical plaque-psoriasis pattern
- Well-defined raised plaques
- Dry white or silvery scale
- Common on elbows, knees, scalp and trunk
- Can itch, crack, bleed or feel painful
- Nail pitting and lifting may occur
- Joint symptoms may indicate psoriatic arthritis
What about psoriasis on the palms and soles?
Palmoplantar psoriasis can resemble PPP because thick skin on the hands and feet often becomes red, dry, scaly and deeply fissured. The crucial difference is that plaque-type palmoplantar psoriasis is dominated by thickened plaques rather than recurring sterile pustules.
Fungal infection, dyshidrotic eczema and contact dermatitis may also resemble either condition.
Risk factors and biology
Why smoking and genetics help distinguish the conditions.
Smoking and PPP
Smoking is one of the strongest recognised associations with PPP. Some clinical sources report that up to 95% of patients smoke or previously smoked, although percentages vary between populations.
Genetic differences
PPP and plaque psoriasis share some inflammatory mechanisms, but their genetic profiles are not identical. PPP is not strongly linked to the main PSORS1/HLA-Cw6 risk locus in the same way as plaque psoriasis.
Classification varies
Some guidelines classify PPP within psoriasis, while other expert groups and reviews describe it as a distinct clinical entity. That disagreement is why patients may hear different explanations.
Treatment response
Similar treatment names do not mean identical results.
Both conditions may be treated with potent topical corticosteroids, emollients, phototherapy and systemic medicines. The most suitable treatment depends on diagnosis, severity, other medical conditions and previous response.
PPP
PPP is often persistent and treatment-resistant. Options may include topical treatment, PUVA, oral retinoids and other systemic or immune-modulating medicines. Biologics used for plaque psoriasis do not always perform as reliably in PPP.
Plaque psoriasis
Plaque psoriasis has a broader evidence base and more established treatment pathways, including topical therapies, phototherapy, conventional systemic medicines and multiple targeted biologics.
Treatment availability and medicine approvals differ between countries. Do not start, stop or change prescribed treatment without speaking with the prescriber.
How the diagnosis is made
A dermatologist looks at the complete pattern.
There is no single blood test that reliably separates PPP from psoriasis. Diagnosis is based on appearance, distribution, history and sometimes additional testing.
Examine the lesions
Are sterile pustules the dominant feature, or are there sharply defined plaques with thick scale?
Check the distribution
PPP primarily affects palms and soles. Plaques on the scalp, elbows, knees or trunk may support a psoriasis diagnosis.
Review nails and joints
Nail changes occur in both. Joint, bone or chest-wall symptoms may alter the assessment and referral pathway.
Exclude lookalikes
Skin scraping or fungal culture can help exclude infection. Patch testing or biopsy may be useful when the diagnosis remains unclear.
Bring photographs to the appointment
PPP changes rapidly as pustules appear, dry and peel. Dated photographs from several stages can be more informative than the skin's appearance on one appointment day.
Can the diagnoses overlap?
Yes,PPP and plaque psoriasis can occur in the same person.
PPP with psoriasis elsewhere
A person may have recurring pustules on palms or soles and plaque psoriasis on another body site. This does not make the palm-and-sole eruption identical to an ordinary plaque.
One diagnosis can change over time
Early lesions can be difficult to classify. Follow-up, photographs, treatment response and additional skin findings may help refine the diagnosis.
Seek prompt medical advice
Widespread pustules and fever are not typical of localised PPP.
Seek urgent medical assessment when pustules spread rapidly beyond the palms and soles, large areas of skin become red and painful, or you develop fever, chills, weakness or feel systemically unwell. Generalised pustular psoriasis can be a medical emergency.
Increasing heat, swelling, discharge or rapidly worsening pain may also indicate secondary infection or another diagnosis.
My experience with misdiagnosis
Why the distinction mattered to me.
Before receiving a PPP diagnosis, I was given several different explanations for my skin, including eczema, scabies and fungal infection. The uncertainty delayed my understanding of what I was dealing with.
My experience can offer context, but it cannot diagnose another person's skin. A correct clinical assessment remains the foundation for appropriate treatment.
Continue learning
Explore the condition in more detail.
What Is PPP?
Symptoms, causes, diagnosis, treatment and when to see a dermatologist.
PPP Pictures
See real palm and sole outbreaks at different stages.
PPP FAQ
Answers about contagion, triggers, treatment, remission and support.
PPP Remission
What remission can mean and the personal path I followed.
PPP Resources
Browse all guides, articles, photographs and support links.
The PPP Book
Learn about my complete practical framework and personal journey.
Sources and further reading
Medical references used for this comparison.
- British Association of Dermatologists. Palmoplantar pustulosis. Read the patient guidance.
- British Association of Dermatologists. Psoriasis,an overview. Read the overview.
- DermNet. Palmoplantar pustulosis. Read the clinical summary.
- DermNet. Palmoplantar psoriasis. Read the clinical summary.
- Heidemeyer K, et al. Palmoplantar Pustulosis: A Systematic Review of Risk Factors and Therapies. Read the systematic review.
- Mössner R, et al. Palmoplantar pustulosis: pathogenesis, differential diagnosis and treatment. Read the 2026 review.
Medical information:
This page is for informational and educational purposes. It does not
diagnose skin disease or replace care from a qualified healthcare
professional. Photographs and written descriptions alone cannot reliably
distinguish PPP, psoriasis, eczema, fungal infection or other skin conditions.
Seek prompt care for widespread pustules, fever, severe pain, rapidly
worsening symptoms or signs of infection.