Increased expression of IL-17A and limited involvement of IL-23 in patients with palmo-plantar (PP) pustular psoriasis or PP pustulosis; results from a randomised controlled trial

J Eur Acad Dermatol Venereol. 2014 Oct;28(10):1298-305. doi: 10.1111/jdv.12272. Epub 2013 Sep 24.


Background: Palmo-plantar pustular psoriasis (PPPP) and palmo-plantar pustulosis (PPP) are chronic skin diseases with significant impact on quality of life.

Objectives: The purpose of this study was to study the efficacy of ustekinumab in PPPP and PPP and gain more knowledge on the pathophysiology and the role of the interleukin-23 (IL-23) signalling pathway in these diseases.

Methods: Thirty-three patients with either PPPP (20) or PPP (13) and seven volunteers with normal palmo-plantar skin were recruited. Patients with PPP or PPPP were randomised (1 : 1) to receive either an anti IL-12/IL-23 antibody (ustekinumab 45 mg) or placebo at day 0 and week 4 with subsequent placebo cross-over to ustekinumab at week 16. The primary endpoint was the proportion of patients randomized to ustekinumab achieving a 50% improvement in the Palmo-Plantar Pustular Area and Severity Index (PPPASI-50) as compared to placebo. Skin biopsies of the palms and soles of normal subjects and patients with PPP or PPPP were performed and analysed by RT-PCR and immunohistochemistry.

Results: There was no statistically significant difference in the proportion of patients randomised to ustekinumab as compared to those randomised to placebo achieving PPPASI-50 at week 16 for patients with PPPP (10%, 20%; P = 1.000) or PPP (20%, 37.5%; P = 1.000) respectively. Compared to normal subjects an 89-fold increase in IL-17A expression was found in palms/soles of patients with PPPP (P = 0.006) and a 190-fold increase for patients with PPP (P = 0.051). There were no statistically significant changes in cytokine expression at week 16 in the palms and soles of patients with PPP or PPPP.

Conclusion: Taken together these results suggest that ustekinumab at a dose of 45 mg has limited efficacy in PPPP and PPP. IL-17A may have a more important role than IL-23 in patients with PPPP and PPP. Conclusions are limited by the small sample size of this study.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antibodies, Monoclonal, Humanized / therapeutic use*
  • Biopsy
  • Cross-Over Studies
  • Female
  • Gene Expression Regulation / physiology*
  • Humans
  • Immunohistochemistry
  • Interleukin-17 / genetics*
  • Interleukin-17 / metabolism
  • Interleukin-23 / genetics*
  • Interleukin-23 / metabolism
  • Male
  • Middle Aged
  • Prognosis
  • Psoriasis / drug therapy*
  • Psoriasis / genetics
  • Psoriasis / metabolism
  • Quality of Life
  • RNA, Messenger / genetics
  • Real-Time Polymerase Chain Reaction
  • Ustekinumab


  • Antibodies, Monoclonal, Humanized
  • Interleukin-17
  • Interleukin-23
  • RNA, Messenger
  • Ustekinumab