What are the treatment options for guttate psoriasis?

Treatment Options for Guttate Psoriasis

Guttate psoriasis is primarily treated with topical therapies, ultraviolet B phototherapy, and antibiotics for associated streptococcal infections, with most cases being self-limiting within 3-4 months. 1

First-Line Treatment Options

Topical Therapies

• Topical corticosteroids: First-line therapy for mild cases
  • Start with moderate potency (class 2-5) for most body areas
  • Use lower concentrations for sensitive areas (face, flexures, genitalia)
  • Can be combined with vitamin D analogues for enhanced efficacy 1

Coal Tar and Dithranol

• Coal tar preparations:

  • Start with low concentrations (0.5-1.0% crude coal tar in petroleum jelly)
  • Gradually increase to maximum 10% as tolerated
  • Erupting guttate psoriasis is less tolerant of topical treatments, so use low concentrations 2

• Dithranol (anthralin):

  • Start with low concentrations (0.1-0.25%)
  • Use "short contact mode" (15-45 minutes daily)
  • Increase concentration gradually as tolerated 2

Phototherapy

• Ultraviolet B (UVB) radiation: Especially helpful for guttate psoriasis 2, 1
  • Narrowband UVB has the most robust evidence for effectiveness 3
  • First-line therapy for moderate-to-severe guttate psoriasis 4
  • More practical than topical therapy when treating widespread or numerous small lesions 4

Antibiotic Treatment

• Investigate for streptococcal infection in acute guttate psoriasis 2
• Treat persistent streptococcal infection with:
  • Phenoxymethyl penicillin or
  • Erythromycin (for penicillin-allergic patients) 2
• Consider penicillin as adjunctive therapy with topical treatments, as the disease may be triggered by streptococcal infection 5

Treatment Algorithm Based on Severity

Mild Guttate Psoriasis

1. First-line: Topical corticosteroids and calcipotriol cream 3
2. Adjunctive: Antibiotics if streptococcal infection is present 2

Moderate to Severe Guttate Psoriasis

1. First-line: Phototherapy (narrowband UVB) with topical treatments 3, 4
2. Second-line: Methotrexate or cyclosporine for cases not responding to first-line therapy 3
3. Third-line: Biologics for severe and refractory cases 3

Special Considerations

• Self-limiting nature: Many cases resolve spontaneously within 3-4 months without treatment 1, 4
• Progression risk: Up to 39% of cases may progress to chronic plaque psoriasis 3
• Recurrent attacks: Repeated episodes of guttate psoriasis after documented tonsillitis may warrant referral to an otolaryngologist for consideration of tonsillectomy 2

Treatment Pitfalls to Avoid

• Misdiagnosis: Guttate psoriasis may be misdiagnosed as an allergy to antibiotics being used to treat streptococcal infection, delaying proper treatment 6
• Overtreatment: Given the possibility for spontaneous remission, active treatment may not be necessary except for cosmetic purposes or because of pruritus 4
• Undertreatment: Given the high rates of persistence and progression to chronic plaque psoriasis, some experts recommend active treatment 4
• Antibiotic uncertainty: Evidence regarding antibiotic therapy suggests minimal connection between underlying infection resolution and guttate psoriasis lesion remission 3, 7

Monitoring and Follow-up

• Regular clinical review for patients on topical corticosteroids
• Monitor for side effects of treatments
• Assess for progression to chronic plaque psoriasis
• Consider maintenance therapy after initial clearance for prolonged control 1