Primary Palmoplantar Pustulosis ( 2 фото )

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A 60-year-old man with a 30-pack-year smoking history presented to the dermatology clinic with a 2-year history of a painful rash on his palms and soles. Previous treatment with various antibacterial agents had been ineffective. Physical examination was notable for numerous pustules, with superficial erosions, purulent crusting, and surrounding erythema, on the palms (Panel A) and soles. Brown macules consistent with nicotine stains were also noted on several fingertips. Laboratory testing revealed neutrophilic leukocytosis and an elevated C-reactive protein level. A potassium hydroxide preparation of a skin scraping from the right sole was negative for fungal elements. A diagnosis of primary palmoplantar pustulosis was made. Primary palmoplantar pustulosis is a chronic inflammatory skin condition characterized by sterile pustules and is highly associated with cigarette smoking. Treatment with a brief course of topical triamcinolone, applied under occlusion, and oral cyclosporine was initiated. Cyclosporine was discontinued owing to drug-induced hypertension, and treatment with dapsone was started because of its antineutrophilic properties and because the dose can be adjusted as needed to maintain a response. At a follow-up visit 1 month after the initial presentation, the rash had abated (Panel B). At 9 years after presentation, the rash remained in remission, with the patient continuing to receive dapsone at a twice-weekly dose of 25 mg. Smoking cessation resources were recommended, but the patient declined.
Leila Shayegan, M.D., and Ruth Ann Vleugels, M.D., M.P.H.
Published January 14, 2026
N Engl J Med 2026;394: e5
DOI: 10.1056/NEJMicm2505935
VOL. 394 NO. 3


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