Treatment Options for Guttate Psoriasis
Guttate psoriasis is primarily treated with topical therapies (low-concentration tar and dithranol), ultraviolet B phototherapy, and antibiotics for associated streptococcal infections, with most cases being self-limiting within 3-4 months. 1, 2
Understanding Guttate Psoriasis
Guttate psoriasis presents as numerous small, teardrop-shaped, scaly erythematous papules and plaques, typically scattered on the trunk and proximal extremities. It often follows a streptococcal infection by 3-4 weeks and may be self-limiting in many cases.
First-Line Treatment Options
Topical Therapies
Topical corticosteroids: Use lower potency formulations as guttate psoriasis is less tolerant of topical treatments 1
- Start with class 2-5 (moderate potency) for body areas
- Avoid prolonged use of high-potency steroids to prevent skin atrophy, striae, and other side effects
Coal tar preparations: 1
- Start with low concentrations (0.5-1.0% crude coal tar in petroleum jelly)
- Can gradually increase concentration to maximum of 10% as tolerated
- Safe but messy to use; cruder tar extracts are generally more effective than refined products
Dithranol (anthralin): 1
- Start with low concentrations (0.1-0.25%)
- Use "short contact mode" (15-45 minutes daily)
- Warn patients about skin irritation and staining of skin and clothes
- Avoid on face, flexures, and genitalia
- Calcipotriene or calcitriol alone or in combination with corticosteroids
- Effective for mild cases
Phototherapy
- Ultraviolet B (UVB) radiation: Especially helpful for guttate psoriasis 1, 2, 3
- Narrowband UVB has the most robust evidence for effectiveness
- Treatment typically given every 48 hours
- Course usually lasts 8-10 weeks
- Should be supervised by experienced clinicians with proper equipment calibration
Antibiotic Treatment
- For associated streptococcal infections: 1, 2
- Phenoxymethyl penicillin or erythromycin (if penicillin allergic)
- Investigate for streptococcal infection with throat swabs
- Consider antibiotics even though evidence regarding connection between infection resolution and psoriasis remission is mixed 4
Second-Line Treatment Options
Systemic Therapies
For moderate-to-severe cases that fail to respond to first-line treatments: 3, 5
- Methotrexate
- Cyclosporine
Third-Line Options
For severe and refractory cases: 3, 5
- Biologics (TNF-α inhibitors like adalimumab, infliximab, etanercept)
Special Considerations
Natural Course
- Many cases of guttate psoriasis are self-limiting and resolve within 3-4 months 1, 5
- Up to 40-50% may persist and progress to chronic plaque psoriasis 5
Recurrent Episodes
- For repeated attacks following documented tonsillitis, consider referral to otolaryngologist for tonsillectomy evaluation 1
- Limited evidence supports tonsillectomy for chronic plaque psoriasis that developed from guttate psoriasis 4
Treatment Pitfalls to Avoid
- Do not use commercial sunbeds (emit UVA) as they are rarely effective and may cause premature skin aging 1, 2
- Avoid simultaneous use of salicylic acid with calcipotriene as acid pH can inactivate calcipotriene 2
- Avoid abrupt discontinuation of topical corticosteroids to prevent rebound phenomenon 2
- Do not use systemic corticosteroid monotherapy as skin disease can flare during or after taper 2
Treatment Algorithm
Mild cases:
- Topical corticosteroids (moderate potency) and/or vitamin D analogues
- Low concentration coal tar or dithranol preparations
- Investigate and treat streptococcal infections if present
Moderate-to-severe cases:
- Narrowband UVB phototherapy (most effective option)
- Combined with topical treatments
- Antibiotics if streptococcal infection is present
Refractory cases:
- Consider systemic agents (methotrexate or cyclosporine)
- Biologics for severe cases not responding to other therapies
Regular monitoring is essential to assess treatment response and adjust therapy accordingly. The goal is to achieve clear or almost clear skin while minimizing side effects and preventing progression to chronic plaque psoriasis.