What is the diagnosis and treatment for guttate psoriasis?

From the Guidelines

Guttate psoriasis should be treated with narrowband UVB phototherapy, which has been shown to be highly effective in achieving clearance, with an average of 15-20 treatments required, as recommended by the guidelines of care for the management of psoriasis and psoriatic arthritis 1. The treatment of guttate psoriasis typically begins with confirming and addressing any underlying streptococcal infection using antibiotics like penicillin or amoxicillin for 10 days. For the skin lesions, first-line treatment includes:

• Topical corticosteroids (such as triamcinolone 0.1% cream twice daily)
• Moisturizers to reduce inflammation and maintain skin hydration. In more widespread cases, phototherapy with narrowband UVB light administered 2-3 times weekly for 6-12 weeks is highly effective, with a remission rate of 38% after 1 year, as compared to broadband UVB, which has a remission rate of 5% after 1 year 1. In severe or resistant cases, systemic medications like methotrexate (starting at 7.5-15mg weekly) or biologics may be necessary, with methotrexate being the most commonly prescribed traditional systemic therapy worldwide for psoriasis, and can be used in combination with biologic agents 1. Patients should avoid:
• Skin trauma
• Stress
• Certain medications that can trigger flares. Most cases of guttate psoriasis resolve within a few weeks to months with appropriate treatment, though some patients may develop chronic plaque psoriasis later, and the condition results from an abnormal immune response where T-cells attack healthy skin cells, causing rapid cell turnover and the characteristic lesions, with acitretin being an alternative option for guttate or moderate to severe psoriasis, as recommended by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients 1.

From the FDA Drug Label

Psoriasis: Methotrexate is indicated in the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by a biopsy and/or after dermatologic consultation The answer to the question about Guttate Psoriasis is not directly addressed in the provided drug labels.

• The methotrexate (PO) label 2 mentions psoriasis, but does not specifically address Guttate Psoriasis.
• The triamcinolone acetonide (TOP) label 3 mentions psoriasis, but also does not specifically address Guttate Psoriasis. No conclusion can be drawn about the use of these medications for Guttate Psoriasis.

From the Research

Definition and Characteristics of Guttate Psoriasis

• Guttate psoriasis is a variant of psoriasis characterized by scattered "drop-like" papules and plaques, accounting for up to a quarter of psoriasis cases 4.
• It typically presents with an abrupt onset of numerous, small, scattered, tear-drop-shaped, scaly, erythematous, pruritic papules and plaques, often on the trunk and proximal extremities 5.
• Guttate psoriasis may be triggered by a streptococcal infection, with the Koebner phenomenon being characteristic 5.

Treatment Options for Guttate Psoriasis

• Topical corticosteroids and calcipotriol creams have the most evidence for efficacy in treating guttate psoriasis 4.
• Phototherapy, particularly narrowband ultraviolet B (UVB), has the most robust evidence for treating guttate psoriasis 4.
• Systemic therapies, including traditional immunosuppressants, antibiotics, retinoids, and biologics, may be considered for patients with moderate-to-severe guttate psoriasis who fail to respond to phototherapy and topical therapies 4, 5.
• Antibiotics may be used as supportive therapy if applicable, although evidence regarding antibiotic therapy suggests minimal connection between underlying infection resolution and GP lesion remission 4, 6, 7.

Management and Prognosis of Guttate Psoriasis

• Guttate psoriasis may spontaneously remit within 3-4 months with no residual scarring, may intermittently recur, and in 40-50% of cases, may persist and progress to chronic plaque psoriasis 5.
• Active treatment may not be necessary except for cosmetic purposes or because of pruritus, although some authors suggest active treatment of this condition due to the high rates of persistence and progression to chronic plaque psoriasis 5.
• A proposed treatment algorithm includes topical corticosteroids and calcipotriol cream, in combination with phototherapy, as first-line therapy, with methotrexate or cyclosporine as second-line therapy, and biologics as third-line treatment for severe and refractory cases 4.