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PubMed This is a summary of 14 peer-reviewed journal articles Updated
Dermatology

Decoding Your Scores and Lab Reports

At a Glance

The PPPASI score is a tool doctors use to measure palmoplantar pustulosis severity on a scale of 0 to 72. Skin biopsies for PPP typically show sterile pustules, indicating the blisters are caused by immune system inflammation rather than an active infection.

When you look at your medical records, you will often find complex numbers and technical terms that your doctor uses to track the status of your Palmoplantar Pustulosis (PPP). These tools—clinical scoring systems and pathology reports—allow your medical team to move beyond “better” or “worse” and use objective data to guide your treatment plan.

Decoding the Score: PPPASI

The PPPASI (Palmoplantar Pustulosis Area and Severity Index) is the standard method doctors use to measure the severity of your condition [1][2]. The total score ranges from 0 (no disease) to 72 (very severe) [1].

To calculate this, your doctor looks at three key physical features and grades each from 0 to 4:

  • Erythema: The intensity of the redness [3].
  • Pustules: The number and density of the white or yellow blisters [3].
  • Desquamation: The amount of scaling or peeling [3].

This grade is then multiplied by an Area score (0–6), which represents how much of your palms or soles are affected (e.g., a score of 1 means less than 10% is covered, while a score of 6 means 90–100% is covered) [4]. A total score of 10 or higher is generally considered “severe” and may suggest that more intensive treatment, like a biologic, is needed [2].

Reading Your Pathology Report

If you had a skin biopsy, a pathologist looked at a small sample of your skin under a microscope. Here is how to translate the most common technical terms you might see in that report:

Technical Term Plain English Translation
Sterile Pustule A pocket of pus that contains no bacteria or fungi; it is caused purely by your immune system [5][6].
Neutrophilic Infiltrate A heavy presence of “neutrophils,” which are first-responder immune cells that cause inflammation and form pustules [7][8].
Acanthosis Thickening of the skin’s outer layer, which happens because the skin is growing too fast in response to inflammation [9].
Parakeratosis A sign that skin cells are reaching the surface before they are fully mature; this is what causes the “silvery” or “flaky” scales [10].
Kogoj’s Pustule A very specific, “sponge-like” cluster of immune cells inside the skin layers that is a hallmark of PPP and psoriasis [11][12].

Why These Details Matter

Tracking your PPPASI score allows you and your doctor to see if a treatment is working, even if it feels like progress is slow. For instance, you might notice that while you still have redness, your “Pustule” score has dropped from a 4 to a 1, which is a major sign of improvement [3][13]. Similarly, confirming “sterile” pustules on a pathology report is vital because it ensures you aren’t being treated for a fungal or bacterial infection that isn’t actually there [6][14]. This “audit” of your own records empowers you to have more informed conversations with your care team about Treatment Strategies.

Common questions in this guide

What is a PPPASI score?
The PPPASI (Palmoplantar Pustulosis Area and Severity Index) is a scoring system used by doctors to measure the severity of your condition. It ranges from 0 to 72 and evaluates the intensity of redness, pustules, and scaling, as well as the total area of skin affected on your palms and soles.
What does a PPPASI score of 10 or higher mean?
A total PPPASI score of 10 or higher is generally classified as severe disease. This score often suggests to your dermatologist that more intensive treatments, such as biologic medications, may be necessary to control your symptoms.
What are sterile pustules?
Sterile pustules are pockets of pus that do not contain any bacteria or fungi. In palmoplantar pustulosis, these blisters are caused entirely by your immune system's inflammatory response rather than an infection.
What does Kogoj's pustule mean on my pathology report?
A Kogoj's pustule is a specific, sponge-like cluster of immune cells found inside the layers of the skin. It is a classic hallmark finding on a pathology report that helps confirm a diagnosis of palmoplantar pustulosis or psoriasis.
Why is my skin thickening with PPP?
Thickening of the skin, noted as 'acanthosis' on a lab report, occurs because your skin cells are growing and multiplying too rapidly. This accelerated growth is a direct response to the underlying inflammation caused by the condition.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What was my total PPPASI score today, and how has it changed since my last visit?
  2. 2.Does my biopsy report mention 'Kogoj's spongiform pustules' or 'Munro microabscesses', and how do these findings support my diagnosis?
  3. 3.Based on my scoring (0-72), would you classify my current condition as mild, moderate, or severe?
  4. 4.In my pathology results, did you find any evidence of 'parakeratosis' or 'acanthosis' that explains why my skin is thickening?
  5. 5.Were any fungi or bacteria found in the pustules, or were they confirmed as 'sterile neutrophilic pustules'?

Questions For You

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References

References (14)
  1. 1

    Association of Clinical and Demographic Factors With the Severity of Palmoplantar Pustulosis.

    Benzian-Olsson N, Dand N, Chaloner C, et al.

    JAMA dermatology 2020; (156(11)):1216-1222 doi:10.1001/jamadermatol.2020.3275.

    PMID: 32936291
  2. 2

    Palmoplantar Psoriasis: Epidemiological and Clinical Features and Impact on Quality of Life.

    Elinkichari D, Rabhi F, Jaber K, Dhaoui R

    Dermatology practical & conceptual 2024; (14(3)) doi:10.5826/dpc.1403a191.

    PMID: 39122505
  3. 3

    Exploratory Efficacy Evaluation of Apremilast for the Treatment of Japanese Patients with Palmoplantar Pustulosis: 32-Week Results from a Phase 2, Randomized, Placebo-Controlled Study.

    Okubo Y, Terui T, Kobayashi S, et al.

    Dermatology and therapy 2024; (14(7)):1863-1873 doi:10.1007/s13555-024-01195-z.

    PMID: 38896381
  4. 4

    Evaluation of the area subscore of the Palmoplantar Pustulosis Area and Severity Index using an attention U-net deep learning algorithm.

    Paik K, Kim BR, Youn SW

    The Journal of dermatology 2023; (50(6)):787-792 doi:10.1111/1346-8138.16752.

    PMID: 36815336
  5. 5

    An update on therapeutic options for palmoplantar pustulosis: a narrative review and expert recommendations.

    Xu JM, Wang HM, Jin HZ

    Expert review of clinical immunology 2023; (19(5)):499-516 doi:10.1080/1744666X.2023.2185775.

    PMID: 36970858
  6. 6

    Bullous, pseudobullous, & pustular dermatoses.

    Wick MR

    Seminars in diagnostic pathology 2017; (34(3)):250-260 doi:10.1053/j.semdp.2016.12.001.

    PMID: 28108048
  7. 7

    Successful Treatment of Palmoplantar Pustulosis With Apremilast.

    Dorgham N, Crasto D, Skopit S

    Journal of drugs in dermatology : JDD 2021; (20(11)):1255-1256 doi:10.36849/jdd.6098.

    PMID: 34784120
  8. 8

    Comments about the comparative bulk RNA sequencing between palmoplantar pustulosis and dyshidrotic palmoplantar eczema.

    Yatsuzuka K, Muto J, Murakami M

    F1000Research 2024; (13()):1494 doi:10.12688/f1000research.159565.1.

    PMID: 39810849
  9. 9

    Insight into adenosine pathway in psoriasis: Elucidating its role and the potential therapeutical applications.

    Giraulo C, De Palma G, Plaitano P, et al.

    Life sciences 2024; (357()):123071 doi:10.1016/j.lfs.2024.123071.

    PMID: 39307180
  10. 10

    The P2X7 receptor is not essential for development of imiquimod-induced psoriasis-like inflammation in mice.

    Geraghty NJ, Mansfield KJ, Fuller SJ, et al.

    Purinergic signalling 2017; (13(4)):405-415 doi:10.1007/s11302-017-9569-0.

    PMID: 28597172
  11. 11

    IL-36-Driven Inflammation in Generalized Pustular Psoriasis: Immunological Insights from Plaque Psoriasis and Implications for Targeted Therapy.

    Andrzejczak K, Kucharczyk E, Sternak A, et al.

    International journal of molecular sciences 2026; (27(10)) doi:10.3390/ijms27104441.

    PMID: 42196416
  12. 12

    Interleukin-17A and Keratinocytes in Psoriasis.

    Furue M, Furue K, Tsuji G, Nakahara T

    International journal of molecular sciences 2020; (21(4)) doi:10.3390/ijms21041275.

    PMID: 32070069
  13. 13

    Efficacy and Safety of Brodalumab, an Anti-interleukin-17 Receptor A Monoclonal Antibody, for Palmoplantar Pustulosis: 16-Week Results of a Randomized Clinical Trial.

    Okubo Y, Kobayashi S, Murakami M, et al.

    American journal of clinical dermatology 2024; (25(5)):837-847 doi:10.1007/s40257-024-00876-x.

    PMID: 38954226
  14. 14

    IgA pemphigus showing IgA antibodies to desmoglein 1 and 3.

    Hegazy S, Bouchouicha S, Khaled A, et al.

    Dermatology practical & conceptual 2016; (6(4)):31-33 doi:10.5826/dpc.0604a07.

    PMID: 27867744

This page explains Palmoplantar Pustulosis (PPP) scoring and pathology terminology for educational purposes. Always consult your dermatologist to interpret your specific biopsy results and PPPASI score.

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