A 38-year-old woman with pustulosis palmaris et plantaris (PPP) was referred to the dentist with a suspicion of metal allergy (Fig. 1A). She had noticed the symptoms 3 years previously on her palms and legs. As her symptoms did not improve spontaneously, she visited her dermatologist. There, she was recorded as follows: (1) pustules localized only on the palms and soles; (2) no lesions with eczema or psoriasis on any other parts of the body; and (3) no family history of pustulosis. On the basis of these observations, she was diagnosed with PPP. She was treated with topical application of corticosteroids; however, her symptoms did not improve. Her dermatologist then suspected metal allergy and performed a patch test. Her skin reacted positively with chromium sulfate, zinc chloride, and mercury bichloride. Therefore, she was referred to our dental hospital for the investigation of the possible association of PPP with oral restorative materials. Her medical records were unremarkable, except for extremely severe periodontitis, which she was aware of more than 10 years previously; however, she had not received any comprehensive periodontal treatment. On presentation, we first analyzed the restorative materials of the teeth to determine whether they contained any positive elements detected by the patch test. Unfortunately, we could not detect any positive elements in the oral cavity. Her blood chemistry did not indicate any abnormalities. The white blood cell count was 5600/mm3, with differential counts of 49.3% neutrophils, 28.0% lymphocytes, 7.6% monocytes, 14.4% eosinophils, and 0.7% basophils. C-reactive protein was not elevated, as measured by the conventional method. Immunoglobulin G (IgG), IgA, and IgM concentrations were all within the normal range (IgG, 1243.0 mg/dL; IgA, 131.6 mg/dL; IgM, 149.6 mg/dL). Because of these laboratory data, we first treated her periodontitis to determine whether there was a possible relationship of her PPP to severe periodontitis. Her periodontitis was very severe (Fig. 2A,B). The extraction of several teeth, as well as the correction of the shape of the inflamed alveolar bone (the bone supporting the teeth) to a physiological shape, was necessary. We first treated her periodontitis with the topical application of antibiotics (minocycline-HCl ointment) to determine the effect of anti-infectious periodontal treatment on PPP. We administered the antibiotics in every periodontal pocket once a week for a period of 1 month. One month after treatment, her symptoms appeared to improve slightly (Fig. 1B). We next performed surgical treatment, including teeth extractions and correction of the bone shape. Two to three days after surgery, her PPP symptoms worsened suddenly (Fig. 1C), and continued for up to 1 month (Fig. 1D). From 1 month after surgery, however, her symptoms gradually improved and complete remission was observed (Fig. 1E). In addition, although more than 2 years have passed since complete remission, no recurrence has been observed (Fig. 1F).
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