Biologics Linked With Development of Palmoplantar Pustulosis, Palmoplantar Pustular Psoriasis

Adalimumab and infliximab were the most common biologic therapies associated with the onset of palmoplantar pustulosis and palmoplantar pustular psoriasis.

Use of biologic therapies such as adalimumab and infliximab may increase the risk of developing palmoplantar pustulosis (PPP) and palmoplantar pustular psoriasis (PPPP), according to study findings published in International Journal of Dermatology.

As 2 chronic inflammatory skin conditions characterized by eruptions of sterile pustules on the palms and/or soles, PPP and PPPP development has been linked with several risk factors, including smoking, emotional stress, and certain drugs, such as tumor necrosis factor-α (TNF-α) inhibitors.

Although various case reports and case series have detailed the use of biologic treatments such as TNF-α inhibitors (eg, infliximab and adalimumab) to treat PPP, the researchers of the present study note they have also been associated with paradoxical PPP and PPPP onset following biologic therapy.

“Currently, it is unclear which specific biologics are associated with the onset of PPP or PPPP,” they added. “To our knowledge, there is no existing review that summarizes reports of PPP or PPPP onset following biologic therapy.”

They conducted a systematic review of the MEDLINE and Embase databases for articles that reported the clinical features and outcomes of patients with PPP or PPPP associated with the initiation of biologic therapy. Using the term palmoplantar pustulosis and variations of biologics and generic names in the review conducted on September 2, 2020, the researchers also assessed for recommendations on the most successful methods of achieving complete or partial remission of PPP/PPPP.

Of the 383 articles identified by the systematic review, 53 articles including 155 patients with biologic-associated PPP and PPPP met inclusion criteria (mean age, 44.1 years; 71.6% female). The most common indications for biologic use were rheumatoid arthritis (n = 32), ankylosing spondylitis (n = 26), psoriasis or psoriatic arthritis (n = 18), Crohn's disease (n = 15), and inflammatory bowel disease (n = 11).

In their findings, the most common biologics associated with PPP or PPPP were the TNF-α inhibitors adalimumab (43.9%) and infliximab (33.3%), followed by etanercept (4.5%) and certolizumab (4.5%). Interleukin-17 inhibitors, such as secukinumab (7.6%) and brodalumab (1.5%), were reported only in association with PPPP.

Regarding remission of PPP/PPPP, 58.8% of patients reported complete remission in 3.6 months, 23.5% had partial remission in 3.7 months, 11.8% had no resolution, and 5.9% had aggravation with their treatments. The most common treatments that led to complete response were biologic switching (n = 8) and topical corticosteroids (n = 16), including clobetasol propionate cream 0.05% and halobetasol 0.05% ointment.

“Clinicians should anticipate PPP or PPPP as potential drug reactions to biologics such as adalimumab and infliximab,” concluded the study authors. “Large-scale studies are required to confirm our findings and further explore the pathogenesis for biologic-associated PPP and PPPP.”


Lu JD, Lytvyn Y, Mufti A, et al. Biologic therapies associated with development of palmoplantar pustulosis and palmoplantar pustular psoriasis: a systematic review. Int J Dermatol. Published online February 6, 2022. doi:10.1111/ijd.16064

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