Psoriasis of the Hands

Do you have scaly skin on your palms that cracks and bleeds? Do you ever feel embarrassed to shake someone’s hand? Do you sometimes hide your hands at work?

When psoriasis hits the hands, it can feel devastating. Some 45 percent of people with psoriasis grapple with the skin disease on their hands, according to the National Psoriasis Foundation (NPF). Palmoplantar psoriasis (PPP), as it’s known when it’s on the palms of the hands or the soles of the feet, typically affects people with plaque psoriasis — the most common type of psoriasis.

Although palmoplantar psoriasis only covers a small area of the body, the impact on everyday life can be huge. Gripping a coffee cup, making a presentation at work, or just frequently washing your hands during the COVID-19 pandemic can take a physical and emotional toll. “My hands feel like they’ve been stung by 1,000 bees,” explained one member of MyPsoriasisTeam.

In fact, people with palmoplantar psoriasis are twice as likely as people with psoriasis elsewhere to have trouble completing daily activities, according to a 2018 study published in the Journal of the American Academy of Dermatology. “When psoriasis breaks out, cracks, and bleeds on the hands, you can't do much with them,” shared one MyPsoriasisTeam member. Walking on feet with cracked and inflamed skin is also very painful.

PPP is also difficult to treat, because mainstream psoriasis medications don’t work as well on thick, psoriatic skin of the palms and feet. And frequent hand-washing to protect yourself from COVID-19 can exacerbate symptoms, causing cracks or sores that trigger flares (the Koebner phenomenon). “My cracks are deep, and I cry when I wash,” said one member.

Types of Psoriasis on the Hands

Hand psoriasis can appear in various forms. It can show up as red, scaly sores on the palms; pus-filled lesions (known as palmoplantar pustulosis); or a combination of the two.

Palmoplantar Psoriasis

Characterized by thick, red plaques, this form affects about 45 percent of people with plaque psoriasis. The fingernails are also affected in cases of palmoplantar psoriasis about 60 percent of the time.

Palmoplantar Pustulosis

This form of pustular psoriasis affects about 5 percent of people with psoriasis, and it can be severe. Small pus-filled blisters appear on the palms of hands that can later develop into painful, cracked plaques. The pus in this case does not indicate infection, but is caused by inflamation. A person can have palmoplantar pustulosis as well as other forms of psoriasis.

Psoriatic Nail Disease

Thickening, crumbling, discoloration, pitting, and ridging of nails can occur with hand psoriasis. Nail disease, when accompanied by joint pain, may indicate psoriatic arthritis (PsA), a related condition. Symptoms can also be related to (or look like) fungal infection in the nails, and should be properly evaluated by a dermatologist.

Causes of Hand Psoriasis

Hand lesions, like psoriasis elsewhere on the body, are typically caused by an overactive immune system that creates inflammation and overproduction of skin cells, according to the American Academy of Dermatology (AAD).

Scientists believe genetic markers, specifically the human leukocyte antigen Cw6, are linked to the development of palmoplantar psoriasis. Environmental factors — including smoking, stress, skin traumas, and some medications — also play a role. Palmoplantar psoriasis can affect all ages and genders.

The exact cause of pustular psoriasis, however, is not known. The little blisters occur most frequently in current or former smokers and in women. Infection, pregnancy, some medications, and allergies may also trigger pustules on the hands.

Symptoms of Hand Psoriasis

Symptoms include itchy, scaling, reddened skin plaques with a defined, often symmetrical border. Deep, painful cracks or fissures in the skin are common. “Mine started with an ungodly itch and later changed to small red bumps and small dry spots. Now my hands look like I’ve been burned — red, peeling, painful, and itchy,” explained one member of MyPsoriasisTeam.

Because they share some similar symptoms, hand psoriasis can often be confused with hand dermatitis, dyshidrotic eczema, and other skin conditions. For this reason, it’s important to have any skin symptoms on your hands evaluated by a licensed dermatologist.

Diagnosis is made by visual inspection of the hands, as well as the degree of psoriasis elsewhere on the body. Skin scrapings may also be taken to rule out fungal infections, or a biopsy may be taken to confirm the diagnosis.

How Hand Psoriasis Affects Members' Lives

Members of MyPsoriasisTeam talk about feeling embarrassed, isolated, and depressed by psoriasis on their hands. They also share how it has affected their home, work, and social lives:

• “My hands are constantly cut open. They feel like they were caught in a fire.”
• “I'm so tired of hiding my hands.”
• “Cleaning products wreak havoc on my hands.”
• “I can't hold my hands out for change [from a cashier]. They give me strange looks and drop it in my hand.”
• “My hands and fingers feel like they have hot metal bands tightened around them.”
• “I’m a registered nurse and people are always looking at my nails and hands. It’s so frustrating.”

Treatments for Hand Psoriasis

General psoriasis treatments can be prescribed for hand lesions, but they’re not as effective in clearing scales on that part of the body. You may have to try several different oral and topical treatments before finding the right one for you.

Topical Treatments

Over-the-counter and prescription topical treatments (available in creams, ointments, or lotions) are often the first-line option for mild to moderate palmoplantar psoriasis. They’re typically prescribed in combination with moisturizers.

Over-the-Counter Topicals

Salicylic acid and coal tar are low-potency ingredients found in nonprescription creams, gels, lotions, and soaps that can help manage mild to moderate hand symptoms.

Topical Steroids

High-potency topical corticosteroids help reduce swelling and redness by inhibiting inflammatory responses in the body. They lead to short-term remission in about 20 percent of people with psoriasis on the hands. Steroids come in various forms and strengths and should be used sparingly on small areas of the body for no longer than three weeks. Side effects can include skin thinning and changes in pigmentation. Because the skin on the hands is thick, these creams may be more effective — and absorb more quickly — if gloves or plastic wrap are layered on top of the cream.

Nonsteroidal Topicals

Some nonsteroid prescription topicals can effectively treat hand psoriasis, such as the vitamin A derivative Tazorec (tazarotene) or Dovonex (calcipotriene), a synthetic form of vitamin D. They are often prescribed in alternation with steroids. Unlike steroids, these drugs don’t cause skin thinning.

Topical calcineurin inhibitors, such as Protopic (tacrolimus) and Elidel (pimecrolimus), suppress the immune system to control inflammation and can be used longer than steroids. Approved for atopic dermatitis, they’re frequently prescribed off-label to treat hand lesions in combination with topical steroids or systemic treatments.

With any topical treatment, covering (occluding) the area with cotton or plastic gloves is believed to promote healing. “Wearing white cotton gloves helps my hands, but draws attention and Michael Jackson jokes. Maybe I'll dye them flesh-colored,” said one MyPsoriasisTeam member.

Phototherapy

Phototherapy (light therapy) is often prescribed when palmoplantar psoriasis doesn’t respond to topical treatments. Psoralen and UVA (PUVA) , a drug combined with ultraviolet A light treatments, may be used more frequently than narrowband UVB because it penetrates more deeply. Phototherapy is often combined with systemic treatments. Common side effects of phototherapy include redness and itching. Elidel and Protopic can increase sunburn risk. Phototherapy can also increase the risk of skin cancer. To minimize your UV exposure, ask your dermatologist about a UV unit made for the hands only.

DMARDs and Biologics

When standard treatment for hand psoriasis fails, disease-modifying antirheumatic drugs (DMARDs) or biologic medications — drugs targeting proteins that cause inflammation — may be considered. No one treatment works for every person, and you may have to try more than one medication or combination of treatments before finding one that relieves symptoms.

About 66 percent of palmoplantar psoriasis cases are severe. These cases are often treated with methotrexate — an oral DMARD. One study showed that many people with palmoplantar psoriasis experienced a 75 percent improvement in symptoms with methotrexate. Cyclosporine, another DMARD, is a first-line drug that has been highly effective in quickly clearing severe hand psoriasis, but it can only be used for a short time due to risk of renal damage. The oral vitamin A retinoid Soriatane (acitretin) thins out thick plaques and dries up pustules for some people.

Some of the most effective medications for hand psoriasis have been biologic drugs. In one study of 72 people, Humira (adalimumab) cleared all lesions for 33 percent of participants. Enbrel (etanercept) and Taltz (ixekizumab) are also highly effective in reducing red, scaly lesions.

Biologics may increase the risk of infection and cancer. Some biologics may worsen pustular disease.

Hand Care Tips

Psoriatic hands can be easily irritated or injured, so it’s important to take extreme care with your skin. Using moisturizers, being gentle when washing your hands, and avoiding scratches or irritations are important.

Moisturizers

Moisturizers are an essential part of hand psoriasis treatment. These over-the-counter lotions, creams, and ointments help soften and remove dead skin cells. They can prevent psoriasis from getting worse. Apply moisturizers to skin at least once a day, and at night following a warm bath or shower.

Members of MyPsoriasisTeam report good results with thick, hydrating creams and petroleum-based products, such as Vaseline, that form a protective seal over the skin’s surface. Thinner lotions will not be as emollient, so look for thicker, greasier moisturizers to treat the hands.

“I put emollient on my hands, then Vaseline on top, to seal in moisture so they don't split and crack. It seems to be working,” shared one member of MyPsoriasisTeam. Another said, “I use Gold Bond Psoriasis Relief. I no longer scratch myself bloody, and I’m not ashamed to shake hands or let people see my hands.”

Alternative Therapy

Raw honey may be a promising alternative remedy for palmoplantar psoriasis. A 2019 study found that honey’s anti-inflammatory properties reduced scaling and skin thickening for one woman, when applied as a topical dressing with occlusion. Further research is needed, however, before raw honey can be considered a viable alternative therapy.

Hand-Washing

Frequently cleaning your hands to prevent the spread of COVID-19 and other viruses makes good health sense. People with hand psoriasis are advised to wash with soap and water rather than alcohol-based hand sanitizers, which can dry and irritate skin. Moisturize after hand-washing to reduce irritation from soaps, cleansers, and sanitizers.

“I have pustular psoriasis on the palms of my hands and find that ‘normal’ alcohol hand sanitizers cause flare-ups,” said one member of My PsoriasisTeam. “I used sanitizer on my hands, and I screamed and wanted to cry,” shared another.

Choose gentle cleansers that are free of harsh chemicals or irritants, and rinse well. Residual soap can dry the skin and promote chapping and cracking.

You Are Not Alone: Finding Support for Hand Psoriasis

By joining MyPsoriasisTeam, the social network and online community for those living with psoriasis, you gain a support group more than 88,000 members strong. Psoriasis on the hands is a frequent topic of discussion.

How does hand psoriasis affect your life? Has your doctor prescribed treatments to manage your symptoms? What creams or ointments have helped reduce scales and let use your hands without pain? Share your tips and experiences in a comment below or on MyPsoriasisTeam.