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PubMed This is a summary of 18 peer-reviewed journal articles Updated
Dermatology · Palmoplantar Pustulosis

A Guide to Treatment Strategies for PPP

At a Glance

Treatment for Palmoplantar Pustulosis (PPP) is a step-by-step process starting with topical steroids and quitting smoking. If symptoms persist, dermatologists may recommend phototherapy, oral medications, advanced biologics like IL-23 inhibitors, or treating hidden infections like tonsillitis.

Treating Palmoplantar Pustulosis (PPP) is often a step-by-step process. Because the disease is so closely linked to both your immune system and external triggers, the most effective plans usually combine skin treatments with a “detective-like” approach to find what is driving the inflammation from within [1][2].

Level 1: Standard Care

The first step of the treatment ladder focuses on calming the skin and eliminating the factors that make PPP worse.

  • Topical Treatments: Most patients start with high-potency corticosteroid ointments and Vitamin D3 analogs (like calcipotriol) [3]. These help reduce redness and slow down the overactive skin cell growth. Note that long-term use of these high-potency creams can cause side effects like skin thinning (atrophy), especially on fragile, cracked skin, so apply them only as directed [3].
  • Trigger Management (Smoking Cessation): Quitting smoking is one of the most powerful things a patient can do; research shows that stopping smoking makes other treatments much more effective [4][5].

The Regional Paradigm: Multidirectional Testing and Surgery

In some regions, particularly in Japan, doctors follow a ‘multidirectional’ approach to find internal triggers—checking for hidden “focal infections” [2].

  • Tonsillitis: Chronic inflammation in the tonsils can fuel skin flares. A tonsillectomy (surgical removal) has been shown to significantly improve skin lesions in many patients [6][5].
  • Dental Issues: Hidden infections in the gums or teeth can also act as triggers [7][8].

Note for patients outside of Japan: Western dermatology typically views PPP as a localized psoriasis variant and does not routinely recommend tonsillectomies unless there is a history of severe, recurrent throat infections [9]. If you feel an infection is driving your condition, advocate for a dental or ENT referral.

Level 2: Phototherapy and Oral Medications

If creams and trigger management aren’t enough, your doctor may move to the next level:

  • Phototherapy: Using specific wavelengths of light (PUVA or narrow-band UV-B) to calm immune cells in the skin [3].
  • Oral Systemics: Medications like acitretin (a retinoid), cyclosporine, or apremilast (a PDE4 inhibitor) work throughout the entire body to lower inflammation [10][11].

Level 3: Advanced Biologics and JAK Inhibitors

For moderate-to-severe PPP that hasn’t responded to earlier steps, advanced targeted therapies are now available. While these “biologics” can be highly effective, they are usually reserved for severe cases due to their high cost, insurance step-therapy requirements, and potential side effects [12].

  • IL-23 Inhibitors (e.g., Guselkumab): This is often considered a leading option for PPP. It has been shown to effectively clear skin and even help with associated joint pain in the chest [13][12].
  • IL-17 Inhibitors (e.g., Ixekizumab, Brodalumab): These target a different inflammatory pathway. While effective for many, they can occasionally cause a “paradoxical flare” (a temporary worsening) in some PPP patients [14][15].
  • IL-36 Inhibitors (e.g., Spesolimab): This is a newer class of medicine specifically designed for pustular types of inflammation [14][16].
  • JAK Inhibitors (e.g., Upadacitinib, Tofacitinib): These are oral “small-molecule” drugs that block multiple inflammation signals at once [17][18].

What to Expect: The Timeline

Be aware that biologic and systemic medications take time to work. It may take several weeks or even months to see significant clearing of the skin. Do not get discouraged and abandon a treatment prematurely before discussing it with your doctor. Tracking your symptoms with tools like the PPPASI score can help you stay motivated while you wait for the medication to take effect.

Common questions in this guide

What is the first-line treatment for PPP?
Most patients start with high-potency corticosteroid ointments and Vitamin D3 analogs. These topical treatments help calm inflammation and slow down overactive skin cell growth, though they must be used carefully to avoid skin thinning.
Why might a doctor recommend a tonsillectomy for palmoplantar pustulosis?
Some cases of PPP are triggered by hidden internal infections, such as chronic tonsillitis. Surgically removing the tonsils has been shown to significantly improve skin lesions in patients whose condition is driven by these focal infections.
How long do biologic medications take to work for PPP?
Biologics and oral systemic medications can take several weeks or even months to show significant clearing of the skin. It is important to track your symptoms and not abandon a treatment prematurely without consulting your dermatologist.
What are IL-23 inhibitors used for in PPP?
IL-23 inhibitors, like guselkumab, are advanced targeted therapies used for moderate-to-severe cases of PPP. They work by blocking specific inflammation signals and have been shown to effectively clear skin and relieve associated chest joint pain.
Can quitting smoking help my palmoplantar pustulosis?
Yes, quitting smoking is one of the most powerful things you can do to manage PPP. Research shows that stopping smoking not only reduces disease flares but also makes other skin treatments work much more effectively.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Based on my current severity, am I a candidate for 'multidirectional testing' for focal infections or dental issues?
  2. 2.If we consider a biologic, why is an IL-23 inhibitor like guselkumab often preferred over other options for PPP?
  3. 3.What are the risks of long-term use of high-potency corticosteroids, and how can we prevent skin thinning?
  4. 4.What are the risks and benefits of trying a JAK inhibitor if my current treatment fails?
  5. 5.How long should we wait to see if our current treatment is working before moving up the 'treatment ladder'?

Questions For You

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References

References (18)
  1. 1

    Palmoplantar pustulosis: Factors causing and influencing the course of the disease.

    Putra-Szczepaniak M, Maj J, Jankowska-Konsur A, et al.

    Advances in clinical and experimental medicine : official organ Wroclaw Medical University 2020; (29(1)):157-163 doi:10.17219/acem/112613.

    PMID: 31990461
  2. 2

    Treatment Guidance for Palmoplantar Pustulosis 2022.

    , Terui T, Kobayashi S, et al.

    The Journal of dermatology 2026; (53(7)):e510-e566 doi:10.1111/1346-8138.70246.

    PMID: 42252553
  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
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    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
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    Treatment outcome and prognostic factors of tonsillectomy for palmoplantar pustulosis and pustulotic arthro-osteitis: A retrospective subjective and objective quantitative analysis of 138 patients.

    Takahara M, Hirata Y, Nagato T, et al.

    The Journal of dermatology 2018; (45(7)):812-823 doi:10.1111/1346-8138.14348.

    PMID: 29732605
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    Retrospective analysis of the clinical response of palmoplantar pustulosis after dental infection control and dental metal removal.

    Kouno M, Nishiyama A, Minabe M, et al.

    The Journal of dermatology 2017; (44(6)):695-698 doi:10.1111/1346-8138.13751.

    PMID: 28150339
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    An Analysis of IgG Antibody to Periodontopathic Bacteria in Serum of Palmoplantar Pustulosis Patients With Periodontitis.

    Murai O, Chiba M, Suzuki K, et al.

    The Journal of dermatology 2025; (52(12)):1811-1818 doi:10.1111/1346-8138.17939.

    PMID: 40977413
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    The oral microbial composition and diversity affect the clinical course of palmoplantar pustulosis patients after dental focal infection treatment.

    Akiyama Y, Minabe M, Inada J, et al.

    Journal of dermatological science 2021; (104(3)):193-200 doi:10.1016/j.jdermsci.2021.11.001.

    PMID: 34823927
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    Guselkumab for the Treatment of Palmoplantar Pustulosis: A Japanese Perspective.

    Yamamoto T

    Clinical pharmacology : advances and applications 2021; (13()):135-143 doi:10.2147/CPAA.S266223.

    PMID: 34188558
  10. 10

    Apremilast is a potentially useful treatment for severe palmoplantar pustulosis with extra-palmoplantar symptoms.

    Fukushima-Nomura A, Takamiyagi S, Kakuta R, et al.

    Skin health and disease 2024; (4(2)):e336 doi:10.1002/ski2.336.

    PMID: 38577036
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    New Oral Therapies for Psoriasis: A Comprehensive Review.

    Goldenberg G, Lanoue J, Dong J

    The Journal of clinical and aesthetic dermatology 2016; (9(8)):25-8.

    PMID: 27672415
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    Efficacy and Safety of Guselkumab in Japanese Patients With Palmoplantar Pustulosis: A Phase 3 Randomized Clinical Trial.

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

    JAMA dermatology 2019; (155(10)):1153-1161 doi:10.1001/jamadermatol.2019.1394.

    PMID: 31268476
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    Small-Molecule Inhibitors and Biologics for Palmoplantar Psoriasis and Palmoplantar Pustulosis: A Systematic Review and Network Meta-Analysis.

    Huang IH, Wu PC, Chiu HY, Huang YH

    American journal of clinical dermatology 2024; (25(3)):347-358 doi:10.1007/s40257-024-00849-0.

    PMID: 38438782
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    The Relative Efficacy of Monotherapies for Palmoplantar Pustulosis and Palmoplantar Psoriasis: A Network Meta-Analysis Study of the Palmoplantar Spectrum.

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    PMID: 41752798
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    Paradoxical palmoplantar pustulosis induced by secukinumab and brodalumab: a report of three cases.

    Mössner R, Pinter A

    European journal of dermatology : EJD 2020; doi:10.1684/ejd.2020.3702.

    PMID: 32293563
  16. 16

    Spesolimab Efficacy and Safety in Patients with Moderate-to-Severe Palmoplantar Pustulosis: A Multicentre, Double-Blind, Randomised, Placebo-Controlled, Phase IIb, Dose-Finding Study.

    Burden AD, Bissonnette R, Navarini AA, et al.

    Dermatology and therapy 2023; (13(10)):2279-2297 doi:10.1007/s13555-023-01002-1.

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    Successful treatment of refractory palmoplantar pustulosis by upadacitinib: report of 28 patients.

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    Janus kinase inhibitor tofacitinib successfully treated palmoplantar pustulosis after switching from secukinumab: A case report and review of the literature.

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This page explains treatment strategies for Palmoplantar Pustulosis (PPP) for educational purposes only. Always consult your dermatologist to determine the safest and most effective treatment plan for your specific skin condition.

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