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Practice

Pustules of the fingers: acrodermatitis continua

Annie Langley and Yuka Asai
CMAJ October 18, 2016 188 (15) 1105; DOI: https://doi.org/10.1503/cmaj.150955
Annie Langley
School of Medicine (Langley); Division of Dermatology (Asai), Department of Medicine, Queen’s University, Kingston, Ont.
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  • For correspondence: alangley@qmed.ca
Yuka Asai
School of Medicine (Langley); Division of Dermatology (Asai), Department of Medicine, Queen’s University, Kingston, Ont.
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A woman in her fifties presented with pustules on her right thumb and left index finger (Figure 1). She reported picking the affected skin, which subsequently worsened the condition over one year. There was no personal or family history of psoriasis. Her condition improved with topical clobetasol propionate, calcipotriol and avoidance of trauma. Her hands worsened several months later, and plaque-type psoriasis developed on her body, requiring methotrexate (15 mg/wk). After several months of treatment with methotrexate, she stopped the medication because of adverse effects and minimal response. She was not interested in pursuing any further systemic treatment at the time.

Figure 1:
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Figure 1:

(A) Right thumb of a woman in her fifties showing well-defined, erythematous, scaly plaque over the palmar aspect of the distal phalanx. Note the remnant of pustules in the centre of the plaque. (B) The patient’s left index finger showing anonychia with well-defined erythema, edema and crusting of the distal phalanx.

Acrodermatitis continua (of Hallopeau) is a rare variant of pustular psoriasis. Disease incidence is difficult to estimate given the rarity of the disease, with about 100 case reports.1 The condition presents with sterile acral pustules, often restricted to one or two digits of the hands and feet. Nail-bed and matrix involvement may lead to onychodystrophy, anonychia and osteolysis.2 Acrodermatitis continua has a relapsing course and may be refractory to standard psoriasis therapies such as steroids, calcipotriol, phototherapy, acitretin and immunosuppressants (e.g., methotrexate and cyclosporine). Recent literature describes successful treatment with newer biologic agents for refractory cases.1–3 However, anti–tumour necrosis factor therapies have been found to cause pustular psoriasis and acrodermatitis continua.4 Aggressive treatment is warranted given the destructive tendency of the disease, potentially leading to resorptive osteolysis of digits.1,2

Acrodermatitis continua is commonly misdiagnosed as bacterial, viral or fungal paronychia because of purulence and nail involvement. The differential diagnosis includes dyshidrotic eczema, contact dermatitis and squamous cell carcinoma.5 Histopathologic, Gram stain, KOH and culture testing to rule out infection and other causes of pustules can aid in the diagnosis. However, progression of the disease is often what leads to the diagnosis. Accurate diagnosis is imperative; early treatment of this condition is important to avoid its destructive and disabling effects.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • The authors have obtained patient consent.

References

  1. ↵
    1. Sehgal VN,
    2. Verma F,
    3. Sharma S,
    4. et al
    . Acrodermatitis continua of Hallopeau: evolution of treatment options. Int J Dermatol 2011;50:1195–211.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Yerushalmi J,
    2. Grunwald MH,
    3. Hallel-Halevy D,
    4. et al
    . Chronic pustular eruption of the thumbs. Diagnosis: acrodermatitis continua of Hallopeau (ACH). Arch Dermatol 2000;136:925–30.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Saunier J,
    2. Debarbieux S,
    3. Jullien D,
    4. et al
    . Acrodermatitis continua of Hallopeau treated successfully with ustekinumab and acitretin after failure of tumour necrosis factor blockade and anakinra. Dermatology 2015;230:97–100.
    OpenUrlPubMed
  4. ↵
    1. Ibis N,
    2. Hocaoglu S,
    3. Cebicci MA,
    4. et al
    . Palmoplantar pustular psoriasis induced by adalimumab: a case report and literature review. Immunotherapy 2015;7:717–20.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Lefkir S,
    2. Slimani S,
    3. Brahimi N,
    4. et al
    . Successful treatment of acrodermatitis continua of Hallopeau associated with psoriatic arthritis with adalimumab. Eur J Rheumatol 2015;2:78–9.
    OpenUrlCrossRefPubMed
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Canadian Medical Association Journal: 188 (15)
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Vol. 188, Issue 15
18 Oct 2016
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Pustules of the fingers: acrodermatitis continua
Annie Langley, Yuka Asai
CMAJ Oct 2016, 188 (15) 1105; DOI: 10.1503/cmaj.150955

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Pustules of the fingers: acrodermatitis continua
Annie Langley, Yuka Asai
CMAJ Oct 2016, 188 (15) 1105; DOI: 10.1503/cmaj.150955
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