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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Rheumatology · Pustulotic Arthro-Osteitis and SAPHO Syndrome

When Your Skin Affects Your Bones: PAO and SAPHO Syndrome

At a Glance

People with Palmoplantar Pustulosis (PPP) may experience bone and joint pain due to related inflammatory conditions like Pustulotic Arthro-Osteitis (PAO) or SAPHO syndrome. This sterile inflammation most commonly affects the chest wall but can be managed with targeted rheumatology treatments.

It is not uncommon for people with Palmoplantar Pustulosis (PPP) to experience unexplained aches and pains in their bones or joints. For a long time, patients and even some doctors didn’t realize these symptoms were connected. However, we now know that the same inflammation that causes pustules on your skin can also affect your skeletal system [1][2].

What is PAO and SAPHO?

Two closely related conditions are often associated with the bone and joint pain found in PPP patients:

  • Pustulotic Arthro-Osteitis (PAO): This is a condition where the “arthro” (joints) and “osteo” (bones) become inflamed in connection with your skin pustulosis [3]. It is very common in PPP patients, particularly in Japan, and is considered a major complication of the disease [3][4].
  • SAPHO Syndrome: This is an acronym for a cluster of symptoms: Synovitis (joint lining inflammation), Acne, Pustulosis (like PPP), Hyperostosis (abnormal bone thickening), and Osteitis (bone inflammation) [5][2].

In both conditions, the inflammation is sterile, meaning it is caused by your immune system rather than an infection like a virus or bacteria [1][6].

The “Chest Wall” Connection

One of the most characteristic signs of these syndromes is pain in the anterior chest wall [7]. This specifically involves the joints where your collarbones (clavicles) and ribs meet your breastbone (sternum) [8].

  • Symptoms: You might feel a dull ache, sharp pain, or notice visible swelling and redness in the center of your chest [8][9].
  • Other Areas: While the chest is the most common site, you may also experience pain in your spine, pelvis, hips, or even your jaw [2][10]. This pain often feels worse at night or when you first wake up in the morning [10].

Monitoring and Diagnosis

If you have PPP and are experiencing bone or joint pain, it is important to bring it to your doctor’s attention. These complications can sometimes even appear before the skin symptoms develop [11].

To diagnose these conditions, doctors may use specialized imaging:

  • Bone Scintigraphy: A scan that can show “hot spots” of inflammation across your entire skeleton [6].
  • CT or MRI Scans: These can look for hyperostosis (thickening of the bone) or osteitis (swelling within the bone tissue) [12][7].

Taking Action: Seeing a Specialist

While your dermatologist manages your skin, you may need to see a rheumatologist—a doctor who specializes in inflammatory joint and bone diseases [13].

Actionable steps for management include:

  • Pain Management: Over-the-counter anti-inflammatory drugs (NSAIDs) like ibuprofen are often the first step, but they may not be enough for long-term relief [14].
  • Advanced Therapies: Medications such as bisphosphonates (often used for bone density) are sometimes prescribed off-label and can be effective at reducing bone pain in SAPHO syndrome [15][16]. In more severe cases, your doctor might discuss biologics (like TNF or IL-17 inhibitors) or JAK inhibitors to calm the overactive immune response [17][18].
  • Treating Triggers: Interestingly, in some patients, addressing the triggers of their skin flares—such as having a tonsillectomy to treat a chronic focal infection—has also been shown to improve joint and bone pain [19]. For more on these treatment options, refer to A Guide to Treatment Strategies for PPP.

Common questions in this guide

Can Palmoplantar Pustulosis cause joint pain?
Yes, many people with Palmoplantar Pustulosis experience joint and bone pain. This is often due to related inflammatory conditions like Pustulotic Arthro-Osteitis (PAO) or SAPHO syndrome, which cause your immune system to target your skeletal system.
What is SAPHO syndrome?
SAPHO syndrome is an acronym for a cluster of inflammatory symptoms: Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis. It connects skin conditions like PPP with severe bone and joint inflammation, particularly in the chest wall.
Why does my chest hurt with Palmoplantar Pustulosis?
Chest pain in people with PPP is often a sign of PAO or SAPHO syndrome. These conditions frequently cause inflammation in the anterior chest wall, specifically where the collarbones and ribs connect to the breastbone.
How do doctors diagnose PAO or SAPHO syndrome?
Doctors typically diagnose these conditions using specialized imaging tests. Bone scintigraphy, CT scans, or MRIs can reveal areas of active inflammation, bone thickening, or swelling within the bone tissue.
What treatments are available for SAPHO syndrome and PAO?
Treatment is usually managed by a rheumatologist and often starts with anti-inflammatory drugs like NSAIDs. For persistent pain, doctors may prescribe bisphosphonates, biologic medications, or JAK inhibitors to calm the immune system.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Given that I have PPP, could my chest/bone pain be related to Pustulotic Arthro-Osteitis (PAO) or SAPHO syndrome?
  2. 2.Should I see a rheumatologist to evaluate my joint and bone symptoms?
  3. 3.Would a bone scintigraphy, CT scan, or MRI be helpful in looking for signs of hyperostosis or osteitis in my chest wall?
  4. 4.Are there specific treatments, like bisphosphonates or biologics, that could help with both my skin flares and my bone pain?
  5. 5.If I have chronic tonsillitis, could a tonsillectomy potentially improve my joint symptoms as well as my skin?

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

    SAPHO syndrome: current clinical, diagnostic and treatment approaches.

    Demirci Yildirim T, Sari İ

    Rheumatology international 2024; (44(11)):2301-2313 doi:10.1007/s00296-023-05491-3.

    PMID: 37889264
  2. 2

    Papuloerythroderma of Ofuji associated with sternoclavicular arthritis and successful treatment with cyclosporine.

    Kasai E, Habe K, Matsushima Y, et al.

    JAAD case reports 2022; (27()):70-74 doi:10.1016/j.jdcr.2022.07.004.

    PMID: 35990234
  3. 3

    Characteristics of Japanese patients with pustulotic arthro-osteitis associated with palmoplantar pustulosis: a multicenter study.

    Yamamoto T, Hiraiwa T, Tobita R, et al.

    International journal of dermatology 2020; (59(4)):441-444 doi:10.1111/ijd.14788.

    PMID: 31985054
  4. 4

    Clinical Characteristics of Japanese Patients with Palmoplantar Pustulosis.

    Yamamoto T

    Clinical drug investigation 2019; (39(3)):241-252 doi:10.1007/s40261-018-00745-6.

    PMID: 30632109
  5. 5

    A case of bronchiolitis obliterans organising pneumonia associated with SAPHO (synovitis-acne-pustulosis-hyperostosis-osteitis) syndrome.

    Hameed F, Steer H

    BMJ case reports 2017; (2017()) doi:10.1136/bcr-2017-219822.

    PMID: 28765183
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    Clinical features and radiological findings of 67 patients with SAPHO syndrome.

    Okuno H, Watanuki M, Kuwahara Y, et al.

    Modern rheumatology 2018; (28(4)):703-708 doi:10.1080/14397595.2017.1372874.

    PMID: 28880693
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    CT and MRI features of SAPHO syndrome: a report of 6 cases.

    Xu K, Meng Y, Zuo T

    BMC musculoskeletal disorders 2026; (27(1)).

    PMID: 42260489
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    Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) Syndrome: Clinical and Therapeutic Aspects.

    Condé K, Guelngar CO, Mohamed A, et al.

    Cureus 2021; (13(9)):e18332 doi:10.7759/cureus.18332.

    PMID: 34725595
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    The challenging diagnosis of synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome: A rare case report.

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    SAGE open medical case reports 2024; (12()):2050313X241259395 doi:10.1177/2050313X241259395.

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    SAPHO Syndrome Misdiagnosed as Spinal Infection: A Case Series.

    Yang X, Gu J, Zeng C, et al.

    International medical case reports journal 2025; (18()):1329-1341 doi:10.2147/IMCRJ.S526910.

    PMID: 41127865
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    Non-bacterial vertebral osteitis as the first manifestation of pustulotic arthro-osteitis.

    Ueda Y, Yokogawa N, Shimada K

    Modern rheumatology case reports 2023; (7(2)):488-490 doi:10.1093/mrcr/rxad016.

    PMID: 36905395
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    Synovitis, acne, pustulosis, hyperostosis and osteitis syndrome: a single centre study of a cohort of 164 patients.

    Li C, Zuo Y, Wu N, et al.

    Rheumatology (Oxford, England) 2016; (55(6)):1023-30 doi:10.1093/rheumatology/kew015.

    PMID: 26917545
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    Determination of Risk Factors Influencing Psoriatic Arthritis Screening and Evaluation Questionnaire Scores in Palmoplantar Pustulosis: Post Hoc Analysis of EPPPIK Study.

    Kim BS, Jo SJ, Kim DH, et al.

    Dermatology and therapy 2025; (15(8)):2233-2246 doi:10.1007/s13555-025-01460-9.

    PMID: 40551083
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    Guselkumab improves joint pain in patients with pustulotic arthro-osteitis: A retrospective pilot study.

    Ikumi N, Fujita H, Terui T

    The Journal of dermatology 2021; (48(2)):199-202 doi:10.1111/1346-8138.15632.

    PMID: 33051886
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    Efficacy of bisphosphonates in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: a prospective open study.

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    Mandibular involvement in SAPHO syndrome: a retrospective study.

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    Successful Treatment of Refractory Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO) Syndrome and Paradoxical Psoriasis with Secukinumab: A Case Report.

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    A systematic review of recent randomized controlled trials for palmoplantar pustulosis.

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    Tonsillitis as a possible predisposition to synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome.

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This page is for informational purposes only and does not replace professional medical advice. Always consult your dermatologist or rheumatologist to evaluate and treat your specific joint and skin symptoms.

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