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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Dermatology

Treatment Strategy and Management for ACH

At a Glance

Acrodermatitis continua of Hallopeau (ACH) is managed using a progressive treatment ladder. Patients typically begin with topical therapies before advancing to systemic medications or targeted biologics, such as IL-17 and IL-36 inhibitors, which are highly effective for stubborn cases.

Managing Acrodermatitis continua of Hallopeau (ACH) can be a frustrating journey, largely because it is a rare disease with no universally accepted, formal clinical guidelines [1][2]. Because there is no “rulebook,” treatment often requires a personalized approach and a doctor—usually a dermatologist specializing in complex or pustular psoriasis—who is willing to look at the latest clinical research [3][4]. If you need a refresher on the basics, head to our Home Page or review the Biology and Diagnosis.

The Treatment Ladder

Treatment for ACH is generally progressive. If one “rung” of the ladder does not work, you and your doctor move to the next. When starting systemic or biologic treatments, it is important to understand that they take time—often 12-16 weeks—to reach peak effectiveness.

1. Topical Therapies (The First Rung)

Most patients begin with high-potency creams or ointments applied directly to the digits.

  • Corticosteroids: Used to reduce immediate inflammation [5].
  • Calcipotriol: A form of Vitamin D that helps slow down skin cell growth [6].
  • Calcineurin inhibitors: Non-steroidal creams that help modulate the immune response in the skin [6].

2. Traditional Systemic Medications (The Second Rung)

If topicals fail, doctors may prescribe “systemic” drugs that work throughout the entire body.

  • Oral Retinoids (e.g., Acitretin): A classic systemic treatment for pustular variants. Crucial Safety Warning: These are strictly contraindicated in pregnancy (highly teratogenic) and require strict birth control protocols [7].
  • Cyclosporine: Often used for rapid relief during a severe flare because it works quickly to “calm” the immune system [8]. However, it is usually not a long-term solution due to potential side effects on the kidneys and blood pressure [9].
  • Methotrexate: A standard psoriasis treatment that can be effective for some, though ACH is famously resistant (recalcitrant) to it [7].
  • Apremilast: An oral medication that has shown success in some individual cases of ACH [10].

3. Biologic Therapies (The Third Rung)

Biologics are advanced medications given by injection or IV that target very specific parts of the immune system. For many with ACH, these are now considered a potential first-line option rather than a “last resort” [4][1].

  • IL-17 Inhibitors: Drugs like secukinumab, ixekizumab, and bimekizumab target the Interleukin-17 pathway [11][12]. Research suggests these may be more effective for ACH than older biologics like TNF inhibitors [13].
  • IL-36 Inhibitors: Spesolimab is a newer therapy that specifically targets the IL-36 receptor [14]. This is particularly relevant for ACH because the disease is often driven by a “glitch” in the IL-36 pathway [15][16].
  • Safety Risks and Screening: Because biologics suppress specific immune pathways, they increase your risk of infections. Before starting, your doctor must perform pre-treatment screenings, including tests for Tuberculosis (TB) and Hepatitis, to ensure these infections aren’t hiding in your body [14].

Managing “Recalcitrant” Disease

ACH is known for being recalcitrant, meaning it often resists treatment or clears up only to return shortly after [3]. If your condition is not responding:

  • Combination Therapy: Some doctors may use a biologic alongside a systemic drug like apremilast or methotrexate [17].
  • Switching Biologics: If one biologic (like an IL-17 inhibitor) fails, switching to a different one or a different class (like an IL-36 inhibitor) has been shown to help in many patients [18][11].

Avoiding Common Pitfalls

Because ACH is rare, non-specialists may mistakenly treat it as a chronic infection, leading to “antibiotic cycling” where the patient is given multiple rounds of antibiotics that cannot work because the pustules are sterile (not caused by bacteria) [7]. Finding a specialist who understands the pustular psoriasis spectrum and the role of IL-36 signaling is vital for avoiding these delays in care [19][15]. For tips on daily symptom management during these treatments, see our Monitoring and Quality of Life page.

Common questions in this guide

Why aren't antibiotics working for my ACH flare-ups?
ACH causes sterile pustules, meaning they are the result of immune system inflammation rather than a bacterial infection. Because there is no bacteria present, antibiotics will not clear the pustules and can delay you from getting the correct treatment.
What are biologic therapies for Acrodermatitis continua of Hallopeau?
Biologics are advanced medications given by injection or IV that target the specific parts of the immune system causing your inflammation. For ACH, doctors often use IL-17 or IL-36 inhibitors, which can be highly effective when traditional topical or oral medications fail.
Why do oral retinoids like acitretin require strict birth control?
While oral retinoids can be an effective systemic treatment for pustular conditions, they are highly teratogenic, meaning they can cause severe birth defects. Anyone taking these medications must follow strict birth control protocols and cannot use them during pregnancy.
What happens if a treatment stops working for my ACH?
ACH is known to be recalcitrant, meaning it frequently resists treatment or returns after clearing up. If a medication stops working, your dermatologist may adjust your dose, add a combination therapy, or switch you to a different biologic class.
Why do I need TB and Hepatitis screening before starting a biologic?
Because biologics suppress specific parts of your immune system to stop inflammation, they can increase your overall risk of infection. Before starting a biologic, your doctor will screen you for hidden infections like Tuberculosis and Hepatitis to ensure the treatment is safe for you.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Since there are no formal clinical guidelines for ACH, how do you typically decide when it is time to move from topicals to biologics?
  2. 2.Would an IL-17 inhibitor like secukinumab or bimekizumab be a good option for me, given that these are showing success in recent studies?
  3. 3.Is spesolimab (an IL-36 inhibitor) an option for my specific type of ACH, and would genetic testing help confirm if I'm a good candidate?
  4. 4.If we use cyclosporine to calm this flare, what is our plan for a long-term 'maintenance' drug to prevent the next one?
  5. 5.Are there any specific side effects I should watch for with biologics that differ from the side effects of traditional systemic drugs like methotrexate?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (19)
  1. 1

    Etanercept for pediatric acrodermatitis continua of Hallopeau: A case report and literature review.

    Ruggiero A, Patruno C, Napolitano M, et al.

    Dermatologic therapy 2020; (33(6)):e14046 doi:10.1111/dth.14046.

    PMID: 32700773
  2. 2

    Efficacy and safety of TNF blockers and of ustekinumab in palmoplantar pustulosis and in acrodermatitis continua of Hallopeau.

    Husson B, Barbe C, Hegazy S, et al.

    Journal of the European Academy of Dermatology and Venereology : JEADV 2020; (34(10)):2330-2338 doi:10.1111/jdv.16265.

    PMID: 32030802
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    Acrodermatitis continua of Hallopeau: clinical perspectives.

    Smith MP, Ly K, Thibodeaux Q, et al.

    Psoriasis (Auckland, N.Z.) 2019; (9()):65-72 doi:10.2147/PTT.S180608.

    PMID: 31497529
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    Acrodermatitis continua of hallopeau: aggravating factors and treatment outcomes of 96 patients.

    Yuan L, Yu X, Shi Y, et al.

    The Journal of dermatological treatment 2024; (35(1)):2434098 doi:10.1080/09546634.2024.2434098.

    PMID: 39608017
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    Treatment of acrodermatitis continua of Hallopeau with ustekinumab as monotherapy after failure of anti-TNF agents.

    Palacios-Álvarez I, Simal-Gómez G, Mas-Vidal A, Bernad-Alonso I

    Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2018; (16(5)):611-613 doi:10.1111/ddg.13506.

    PMID: 29659137
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    Acrodermatitis continua of Hallopeau successfully treated with adalimumab: A case report.

    Crowley EL, Maliyar K, Rodriguez-Bolanos F, et al.

    SAGE open medical case reports 2019; (7()):2050313X19829620 doi:10.1177/2050313X19829620.

    PMID: 30800311
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    Acrodermatitis continua of Hallopeau successfully treated with ixekizumab: A case report.

    Battista T, Guerrasio G, De Fata Salvatores G, et al.

    Dermatologic therapy 2022; (35(5)):e15383 doi:10.1111/dth.15383.

    PMID: 35174591
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    Short- and Long-Term Management of an Acute Pustular Psoriasis Flare: A Case Report.

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    Journal of cutaneous medicine and surgery 2017; (21(5)):452-456 doi:10.1177/1203475417712499.

    PMID: 28535721
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    Certolizumab Pegol: A New Therapeutic Approach for Acrodermatitis Continua of Hallopeau.

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    Skin appendage disorders 2022; (8(2)):146-149 doi:10.1159/000519144.

    PMID: 35419415
  10. 10

    Nails as immune-privileged sites: A case of disabling Acrodermatitis continua of Hallopeau successfully treated with Apremilast.

    Lanna C, Cesaroni GM, Mazzilli S, et al.

    Dermatologic therapy 2019; (32(4)):e12946 doi:10.1111/dth.12946.

    PMID: 31025500
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    Successful treatment of severe acrodermatitis continua of hallopeau with Bimekizumab: A case report.

    Xu L, Li K, Mutter E, Langley A

    SAGE open medical case reports 2025; (13()):2050313X241311043 doi:10.1177/2050313X241311043.

    PMID: 39850643
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    Outcomes of various types of therapy in patients with treatment-resistant acrodermatitis continua of Hallopeau.

    Smirnova LM, Vertieva EY, Olisova OY, Anpilogova EM

    Biologics : targets & therapy 2019; (13()):83-87 doi:10.2147/BTT.S199100.

    PMID: 31190732
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    A retrospective analysis of 65 patients with acrodermatitis continua of Hallopeau.

    Chularojanamontri L, Silpa-Archa N, Pattamadilok B, et al.

    Experimental dermatology 2024; (33(3)):e15055 doi:10.1111/exd.15055.

    PMID: 38519437
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    Spesolimab in generalized pustular psoriasis complicated by acrodermatitis continua of Hallopeau: a case report and mechanistic insights.

    Hou XY, Xiao HL, Wang JY, et al.

    Frontiers in immunology 2025; (16()):1563553 doi:10.3389/fimmu.2025.1563553.

    PMID: 40443665
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    Successful treatment of acrodermatitis continua of Hallopeau coexisting with generalized pustular psoriasis with spesolimab: a case report.

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    Case report: Successful treatment with spesolimab of acrodermatitis continua of Hallopeau in an older patient without IL36RN mutations.

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    Apremilast Coadministered with Secukinumab for Effective Treatment of Acrodermatitis Continua of Hallopeau: A Case Report.

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This page provides educational information about treatment options for Acrodermatitis continua of Hallopeau. It does not replace professional medical advice. Always consult your dermatologist to determine the safest and most effective treatment plan for your specific condition.

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