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Dental infection as a triggering factor in palmoplantar pustulosis.

Palmoplantar pustulosis (PPP) is a chronic disease characterized by sterile pustules on the palms and soles. Focal infections are closely associated with exacerbation of PPP, often accompanied by arthralgia. Tonsillitis is the most common culprit, whereas reports on dental infection are scarce (1). We describe here 4 cases of PPP in which dental infection is suggested to play a triggering role in the induction or deterioration of the disease. CASE REPORTS Case 1. A 60-year-old man had been treated for PPP for 3 years. He was a non-smoker. Two months previously, his skin eruptions suddenly worsened and spread beyond the palmoplantar areas. Simultaneously, severe joint pain appeared on the sternocosto-clavicular areas, shoulder and sacroiliac joints. On physical examination, small pustules and scales were detected on the erythematous lesions on the palms and soles. In addition, scaly erythema and solitary pustules, which were sterile, were scattered on his trunk (Fig. 1a). Laboratory examination showed increased levels of C-reactive protein (CRP, 3.8 mg/dl, normal 0.00–0.30), white blood cell (WBC) count (9,800/μl, normal 3,800–9,800/ μl), and normal anti-streptolysin O (ASO) titres were elevated (289 IU/ml, normal 0–244 IU/ml). Bone scintigraphy revealed increased uptake in the sternocostoclavicular joints (Fig. 1b), and X-ray of the head revealed dento-alveolar abscess and subsequent sinusitis. Administration of clarithromycin and application of cortico steroid ointment for the skin lesions resulted in improvement in both skin lesions and joint pain (Fig. 1c, d). Thereafter, only slight scaly erythema appeared occasionally on the soles during a 4-year follow-up period, with no recurrence of joint pain. Case 2. A 61-year-old woman suddenly developed pustular lesions on the palms and trunk 5 days previously. Solitary sterile pustules were also scattered on the abdomen and back. She smoked 20 cigarettes of tobaccos a day. A skin biopsy from the pustule revealed neutrophilic abscesses in the epidermis. Laboratory data revealed a slight increase in CRP (0.69 mg/dl) and WBC (10,300/μl). ASO titres were elevated (289 IU/ml, normal 0–244 IU/ml), but laryngological examination revealed no abnormalities. Bone scintigraphy revealed an increased uptake of technetium 99 m in the sternocostoclavicular joints. Ort-hopantomography revealed resorption of the mandible alveolar bone due to periodontitis. Dental examination revealed abscess formation in the pocket of several teeth. Surgical extraction of 4 teeth of dental caries and the application of corticosteroid ointment for the skin lesions resulted in improvement in the skin lesions and in arthralgia. Although the patient did not give …