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Association of Clinical and Demographic Factors with the Severity of Palmoplantar Pustulosis

Lookup NU author(s): Professor Nick ReynoldsORCiD



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


© 2020 American Medical Association. All rights reserved.Importance: Although palmoplantar pustulosis (PPP) can significantly impact quality of life, the factors underlying disease severity have not been studied. Objective: To examine the factors associated with PPP severity. Design, Setting, and Participants: An observational, cross-sectional study of 2 cohorts was conducted. A UK data set including 203 patients was obtained through the Anakinra in Pustular Psoriasis, Response in a Controlled Trial (2016-2019) and its sister research study Pustular Psoriasis, Elucidating Underlying Mechanisms (2016-2020). A Northern European cohort including 193 patients was independently ascertained by the European Rare and Severe Psoriasis Expert Network (2014-2017). Patients had been recruited in secondary or tertiary dermatology referral centers. All patients were of European descent. The PPP diagnosis was established by dermatologists, based on clinical examination and/or published consensus criteria. The present study was conducted from October 1, 2014, to March 15, 2020. Main Outcomes and Measures: Demographic characteristics, comorbidities, smoking status, Palmoplantar Pustulosis Psoriasis Area Severity Index (PPPASI), measuring severity from 0 (no sign of disease) to 72 (very severe disease), or Physician Global Assessment (PGA), measuring severity as 0 (clear), 1 (almost clear), 2 (mild), 3 (moderate), and 4 (severe). Results: Among the 203 UK patients (43 men [21%], 160 women [79%]; median age at onset, 48 [interquartile range (IQR), 38-59] years), the PPPASI was inversely correlated with age of onset (r =-0.18, P =.01). Similarly, in the 159 Northern European patients who were eligible for inclusion in this analysis (25 men [16%], 134 women [84%]; median age at onset, 45 [IQR, 34-53.3] years), the median age at onset was lower in individuals with a moderate to severe PGA score (41 years [IQR, 30.5-52 years]) compared with those with a clear to mild PGA score (46.5 years [IQR, 35-55 years]) (P =.04). In the UK sample, the median PPPASI score was higher in women (9.6 [IQR, 3.0-16.2]) vs men (4.0 [IQR, 1.0-11.7]) (P =.01). Likewise, moderate to severe PPP was more prevalent among Northern European women (57 of 134 [43%]) compared with men (5 of 25 [20%]) (P =.03). In the UK cohort, the median PPPASI score was increased in current smokers (10.7 [IQR, 4.2-17.5]) compared with former smokers (7 [IQR, 2.0-14.4]) and nonsmokers (2.2 [IQR, 1-6]) (P =.003). Comparable differences were observed in the Northern European data set, as the prevalence of moderate to severe PPP was higher in former and current smokers (51 of 130 [39%]) compared with nonsmokers (6 of 24 [25%]) (P =.14). Conclusions and Relevance: The findings of this study suggest that PPP severity is associated with early-onset disease, female sex, and smoking status. Thus, smoking cessation intervention might be beneficial..

Publication metadata

Author(s): Benzian-Olsson N, Dand N, Chaloner C, Bata-Csorgo Z, Borroni R, Burden AD, Cooper HL, Cornelius V, Cro S, Dasandi T, Griffiths CEM, Kingo K, Koks S, Lachmann H, McAteer H, Meynell F, Mrowietz U, Parslew R, Patel P, Pink AE, Reynolds NJ, Tanew A, Torz K, Trattner H, Wahie S, Warren RB, Wright A, Barker JN, Navarini AA, Smith CH, Capon F

Publication type: Article

Publication status: Published

Journal: JAMA Dermatology

Year: 2020

Volume: 156

Issue: 11

Pages: 216-1222

Print publication date: 01/11/2020

Online publication date: 16/09/2020

Acceptance date: 19/06/2020

Date deposited: 14/01/2021

ISSN (print): 2168-6068

ISSN (electronic): 2168-6084

Publisher: American Medical Association


DOI: 10.1001/jamadermatol.2020.3275

PubMed id: 32936291


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Funder referenceFunder name
... London and King’s College Hospital NHS Foundation Trust (guysbrc-2012-1)
APRICOT trial and the PLUM study were funded by the EME Programme, an MRC and NIHR partnership (grant EME 13/50/17 to Drs Smith, Capon, Barker, and Griffiths).
Dr Reynolds is an NIHR Senior Investigator and receives support from the Newcastle MRC/EPSRC Molecular Pathology Node and the Newcastle NIHR Medtech and In Vitro Diagnostic Co-operative.
European Academy of Dermatology and Venereology (grant PPRC-2018-25 to Drs Barker, Capon, and Navarini,
grant PPRC-2012-11 to Drs Navarini and Barker)
Newcastle NIHR Biomedical Research Centre.
NIHR BioResource Clinical Research Facility and comprehensive Biomedical Research Centre awards to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College ...