What are the treatment options for non-plaque psoriasis subtypes, including guttate, inverse, pustular, and erythrodermic psoriasis?

From the Guidelines

Treatment options for non-plaque psoriasis subtypes, including guttate, inverse, pustular, and erythrodermic psoriasis, vary based on the specific form and severity of the condition, with first-line treatments often involving topical corticosteroids, vitamin D analogs, and narrow-band UVB phototherapy, while more severe forms may require systemic treatments such as biologics, cyclosporine, or methotrexate. The following are the treatment options for each subtype:

• Guttate psoriasis: topical corticosteroids (such as triamcinolone 0.1% cream twice daily), vitamin D analogs (calcipotriene), and narrow-band UVB phototherapy administered 2-3 times weekly for 6-12 weeks, with antibiotics prescribed if there's an active streptococcal infection 1.
• Inverse psoriasis: low-potency topical steroids (hydrocortisone 1-2.5%) or steroid-sparing agents like tacrolimus 0.1% ointment or pimecrolimus 1% cream, applied thinly twice daily for 2-4 weeks 1.
• Pustular psoriasis: systemic treatments such as acitretin (starting at 10-25mg daily), cyclosporine (2.5-5mg/kg/day), or methotrexate (starting at 7.5mg weekly), with biologics like IL-17 inhibitors (secukinumab, ixekizumab) or IL-23 inhibitors (guselkumab, risankizumab) for generalized pustular psoriasis 1.
• Erythrodermic psoriasis: urgent care with systemic agents like cyclosporine, infliximab (5mg/kg IV at weeks 0,2, and 6), or newer biologics, with supportive measures including fluid replacement, temperature regulation, and infection prevention 1. A comparison of the treatment options for non-plaque psoriasis subtypes is shown in the following table:

  Subtype	First-line Treatment	Second-line Treatment
  Guttate	Topical corticosteroids, vitamin D analogs, narrow-band UVB phototherapy	Systemic treatments (e.g. acitretin, cyclosporine, methotrexate)
  Inverse	Low-potency topical steroids, steroid-sparing agents	Systemic treatments (e.g. acitretin, cyclosporine, methotrexate)
  Pustular	Systemic treatments (e.g. acitretin, cyclosporine, methotrexate)	Biologics (e.g. IL-17 inhibitors, IL-23 inhibitors)
  Erythrodermic	Systemic agents (e.g. cyclosporine, infliximab, newer biologics)	Supportive measures (e.g. fluid replacement, temperature regulation, infection prevention)

From the Research

Non-Plaque Psoriasis Subtypes

Non-plaque psoriasis subtypes include guttate, inverse, pustular, and erythrodermic psoriasis. These subtypes differ from plaque psoriasis in their clinical presentation and treatment options.

Treatment Options

• Guttate psoriasis:
  • Topical corticosteroids and calcipotriol cream as first-line therapy 2
  • Phototherapy, such as narrowband ultraviolet B (UVB), as a supportive therapy 2
  • Systemic therapies, including traditional immunosuppressants, antibiotics, retinoids, and biologics, as second-line or third-line treatment 2
• Inverse psoriasis:
  • Topical corticosteroids, topical calcineurin inhibitors, and vitamin D analogs as treatment options 3
  • Traditional oral systemic therapies, such as cyclosporine and methotrexate, and biologic therapies may also be used 3
• Pustular psoriasis:
  • Treatment options are similar to those for plaque psoriasis, including topical and systemic therapies 4, 5
• Erythrodermic psoriasis:
  • Treatment options are similar to those for plaque psoriasis, including topical and systemic therapies 4, 5

Comparison of Treatment Options

The following table compares the treatment options for non-plaque psoriasis subtypes:

Subtype	Topical Therapies	Systemic Therapies	Phototherapy
Guttate	Corticosteroids, calcipotriol	Immunossuppressants, antibiotics, retinoids, biologics	Narrowband UVB
Inverse	Corticosteroids, calcineurin inhibitors, vitamin D analogs	Cyclosporine, methotrexate, biologics	-
Pustular	Similar to plaque psoriasis	Similar to plaque psoriasis	-
Erythrodermic	Similar to plaque psoriasis	Similar to plaque psoriasis	-

Note: The treatment options listed are not exhaustive and may vary depending on the individual patient and the severity of the disease. 2, 4, 5, 3, 6