Psoriasis: hyperkeratotic hand / foot psoriasis

Hyperkeratotic hand/foot psoriasis refers to thick areas of scale affecting the palms and/or soles. 

This chapter is set out as follows:

Lesions are usually well-demarcated, although, in the absence of other signs of psoriasis it can be difficult to differentiate from:

• Hyperkeratotic eczema
• Occasionally, tinea 

• Scrapings can be sent for mycology if tinea is part of the differential 

• It is worth providing a patient information leaflet on hand dermatitis (this can be found on the top right of this page) - although this is not the primary diagnosis, many patients will have a degree of irritant contact dermatitis and anything that can be done to make the skin more comfortable is of value

• Emollients containing urea 

• Diprosalic ® ointment is effective for erythema with scale. It is most effective if used at night under occlusion eg cotton gloves for the hands and socks for the feet (see below)

• Very thick scale on the feet can be treated by higher strengths of urea (eg Flexitol 25% ® Urea Heel Balm; various 20% urea products can be purchased online) should be applied to the skin under a damp sock with a dry sock on top, starting 3 nights a week. In Secondary Care 10-20% preparations of salicylic acid in yellow soft paraffin can be used, however, these are often made up as a 'special' and can be costly 

• For patients failing to respond to treatment and/or where diagnostic uncertainty exists eg contact allergic dermatitis, patients should be referred to a specialist for consideration of further investigations such as patch tests and/or systemic treatments. One of the most effective systemic treatments are the retinoids (eg acitretin - Neotigason ®), which can lead to substantial improvements, although are teratogenic