EUH Resident Report: A review of pustular psoriasis

The Bottom Line: Several clinical variants of pustular psoriasis exist: generalized pustular psoriasis (von Zumbusch type), annular pustular psoriasis, impetigo herpetiformis, and two variants of localized pustular psoriasis—(1) pustulosis palmaris et plantaris and (2) acrodermatitis continua of Hallopeau. Treatment of patients with pustular psoriasis depends on the severity of presentation and patient’s underlying risk factors. The literature and data are extremely weak and limited for this type of psoriasis.

Click here for a book chapter on psoriasis, with a section covering pustular psoriasis.

DynaMed Plus provides treatment guidelines recommended by the National Psoriasis Foundation (NPF).

References: 

Gudjonsson, Johann E., and James T. Elder.Chapter 18. Psoriasis.Fitzpatrick’s Dermatology in General Medicine, 8e. Eds. Lowell A. Goldsmith, et al. New York, NY: McGraw-Hill, 2012. n. pag. AccessMedicine. Web. 22 Jan. 2016. <http://accessmedicine.mhmedical.com.proxy.library.emory.edu/content.aspx?bookid=392&Sectionid=41138713&gt;.

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 116742, Psoriasis; [updated 2015 Dec 21, cited 2016 Jan 22]. Available from http://www.dynamed.com/login.aspx?direct=true&site=DynaMed&id=116742. Registration and login required.

Summary: Pustular psoriasis involves monomorphic sterile pustules on painful inflamed skin. There is localized pustular variant involving soles and palms occurring with or without plaque-type disease (palmoplantar psoriasis). The acute generalized disease also called von Zumbusch variant consists of widespread pustules on erythematous background and is an uncommon severe form of psoriasis associated with fever and toxicity.

Treatment: Treatment should be governed by the extent of involvement and severity of disease. Acitretin, cyclosporine, methotrexate, and infliximab are considered to be first-line therapies for those with generalized pustular psoriasis. Adalimumab, etanercept, and psoralen plus ultraviolet A are second-line modalities in this setting. Pustular psoriasis in children, in pregnant women, and in localized forms alter which agents are first-line modalities as concerns such as teratogenicity need to be factored into the decisionmaking for the individual patient.

 

 

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