From the Guidelines
Pustular psoriasis is a severe form of psoriasis that requires immediate medical attention, and treatment typically involves systemic therapies such as acitretin, cyclosporine, or biologics like TNF inhibitors or IL-17 inhibitors. The condition is characterized by the development of sterile pustules on red, inflamed skin, and can be life-threatening if left untreated. According to the most recent guidelines, acitretin is a relatively safe medication that can be effective in treating severe psoriasis variants, including generalized pustular psoriasis, with doses ranging from 10 to 50 mg daily 1.
Diagnosis and Treatment
- The diagnosis of pustular psoriasis is based on clinical presentation and histopathological examination.
- Treatment options for pustular psoriasis include:
- Topical corticosteroids like clobetasol 0.05% applied twice daily for mild cases.
- Systemic treatments such as acitretin (starting at 25-50mg daily), cyclosporine (2.5-5mg/kg/day), or methotrexate (starting at 7.5mg weekly, potentially increasing to 25mg).
- Biologics like TNF inhibitors (adalimumab, etanercept), IL-17 inhibitors (secukinumab, ixekizumab), or IL-23 inhibitors (guselkumab, risankizumab) for severe or refractory cases.
- Infliximab has been shown to be effective in treating generalized pustular psoriasis, with rapid disease clearance and maintenance of response 1.
- Etanercept has also been shown to be beneficial in generalized pustular psoriasis, with clinical efficacy reported in case series and small studies 1.
Management and Prevention
- Patients with pustular psoriasis should avoid triggers like certain medications, infections, and stress.
- Maintaining good skin care with gentle cleansers and moisturizers can support the skin barrier and reduce flare frequency.
- The choice of biologic therapy should be based on clinical need and a careful assessment of risks and benefits of each agent in the context of the individual patient 1.
From the FDA Drug Label
Thirteen cases of transformation of chronic plaque psoriasis to more severe forms of psoriasis have been reported There were 9 cases of pustular and 4 cases of erythrodermic psoriasis. The initial dose of cyclosporine [MODIFIED] should be 2.5 mg/kg/day. Cyclosporine [MODIFIED] should be taken twice daily, as a divided (1.25 mg/kg b.i.d.) oral dose. Patients generally show some improvement in the clinical manifestations of psoriasis in 2-weeks. Satisfactory control and stabilization of the disease may take 12 to 16 weeks to achieve
The diagnosis of pustular psoriasis is not directly addressed in the label, but it is mentioned as a possible transformation of chronic plaque psoriasis. The treatment for pustular psoriasis is not explicitly stated, but cyclosporine can be used to treat psoriasis, with an initial dose of 2.5 mg/kg/day. Key points for treatment include:
- Starting with a dose of 2.5 mg/kg/day
- Increasing the dose by 0.5 mg/kg/day every 2 weeks if significant clinical improvement has not occurred
- Decreasing the dose by 25% to 50% to control adverse events
- Discontinuing treatment if satisfactory response cannot be achieved after 6 weeks at 4 mg/kg/day or the patient's maximum tolerated dose 2
From the Research
Diagnosis of Pustular Psoriasis
- Pustular psoriasis is a group of skin diseases characterized by neutrophil infiltration in the epidermis and formation of sterile pustules 3
- It has been classified into localized and generalized forms 4
- Diagnosis is based on the extent of involvement and severity of disease 4
Treatment of Pustular Psoriasis
- Treatment should be governed by the extent of involvement and severity of disease 4
- First-line therapies for generalized pustular psoriasis include acitretin, cyclosporine, methotrexate, and infliximab 4
- Second-line modalities for generalized pustular psoriasis include adalimumab, etanercept, and psoralen plus ultraviolet A 4
- Biologics, such as anti-TNF-α, anti-IL-12/23, and anti-IL-17A, have shown positive responses in patients with pustular psoriasis 3
- Cyclosporine can be used as a first-line agent for providing immediate symptomatic relief for pustular psoriasis flares 5
- Infliximab in combination with low-dose acitretin can be effective in the long-term management of generalized pustular psoriasis 6
- Systemic monotherapy treatments, including retinoids, cyclosporine, biologics, and dapsone, are possible first-line agents for generalized pustular psoriasis 7