Photo Quiz

Foot Blisters in a 30-Pack-Year Smoker


Am Fam Physician. 2019 Nov 1;100(9):579-580.

A 44-year-old woman with a 30-pack-year smoking history presented with blisters on the sole of her foot that appeared one month prior. She noticed that the skin on her feet had thickened and had dark brown spots, small pustules, and areas of scale throughout. She had no itching or pain. There was no improvement after two four-week courses of topical clotrimazole and naftifine (Naftin). She subsequently developed a similar rash on the palm of her hand.

Examination showed a well-demarcated rash on the sole of the left foot (Figure 1). Results of potassium hydroxide testing were negative.




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Allergic dermatitis.

B. Bullous tinea pedis.

C. Dyshidrotic eczema.

D. Palmoplantar pustulosis.

E. Pitted keratolysis.


The answer is D: palmoplantar pustulosis. This chronic inflammatory skin disease is characterized by sterile pustules and red, scaly skin on the palms and soles. The pustules typically erupt and progress to yellow-brown macules. Hyperkeratosis, scaling, and fissures are also common. The condition occurs mostly in middle-aged adults and has a strong association with smoking. Other risk factors include thyroid disease, stress, medication use (i.e., tumor necrosis factor alpha inhibitors), and streptococcal infections. Metal allergies can exacerbate the condition.1,2 Palmoplantar pustulosis may have a considerable effect on quality of life because burning, pain, and pruritus may lead to difficulty with walking and activities of daily living.3 The condition is also known as pustular psoriasis. Although the relationship of palmoplantar pustulosis to psoriasis is unclear, some regard it as a manifestation of psoriasis.1,2

The diagnosis of palmoplantar pustulosis can be made clinically. A skin biopsy is not usually necessary but can confirm

Address correspondence to Michael Pesqueira, MD, FAAD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Brunasso AM, Puntoni M, Aberer W, et al. Clinical and epidemiological comparison of patients affected by palmoplantar plaque psoriasis and palmoplantar pustulosis: a case series study. Br J Dermatol. 2013;168(6):1243–1251....

2. Misiak-Galazka M, Wolska H, Rudnicka L. What do we know about palmoplantar pustulosis? J Eur Acad Dermatol Venereol. 2017;31(1):38–44.

3. Farley E, Masrour S, McKey J, et al. Palmoplantar psoriasis: a phenotypical and clinical review with introduction of a new quality-of-life assessment tool. J Am Acad Dermatol. 2009;60(6):1024–1031.

4. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. Elsevier; 2016.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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