How to manage a patient with erythrodermic psoriasis who has developed infected skin and is septic?

Management of Erythrodermic Psoriasis with Infected Skin and Sepsis

For patients with erythrodermic psoriasis who have developed infected skin and sepsis, immediate hospitalization with aggressive supportive care, appropriate antibiotic therapy, and postponement of immunosuppressive therapy until sepsis is controlled is essential for reducing mortality. 1

Initial Management (First 24-48 hours)

Sepsis Management

1. Immediate blood cultures before initiating antibiotics
2. Broad-spectrum antibiotics targeting Staphylococcus aureus (including MRSA coverage)
   • Consider vancomycin if MRSA is suspected 2, 3
   • Adjust based on culture results and local resistance patterns
3. Fluid resuscitation and hemodynamic support
4. Monitor for complications of sepsis (renal failure, electrolyte abnormalities)

Skin Care and Supportive Measures

• Wet dressings with mid-potency topical steroids to reduce inflammation 4, 1
• Careful attention to fluid and electrolyte balance with monitoring of ankle edema 1
• Temperature regulation to prevent hypothermia
• Nutritional support to address increased metabolic demands
• Pain management as needed

Management After Sepsis Control

Once sepsis is controlled and blood cultures are negative, systemic therapy for erythrodermic psoriasis can be initiated:

First-Line Systemic Therapy Options

1. Cyclosporine (3-5 mg/kg/day)

   • Most rapidly acting agent with predictable response
   • Typically produces dramatic improvement within 2-3 weeks
   • Limited to a 3-4 month "interventional" course 1
   • Monitor for toxicity, especially in elderly patients or those with renal disease/hypertension

2. Infliximab

   • Rapid onset of action similar to cyclosporine
   • Particularly useful when longer-term therapy is anticipated 5

3. Alternative First-Line Options:

   • Methotrexate (preferably subcutaneous administration) 1
   • Acitretin (slower onset of action, contraindicated in women of childbearing potential) 1

Long-Term Management

After acute disease control (typically 2-3 months):

1. Taper cyclosporine over approximately 2 months
2. Transition to a biologic agent (TNF-alpha inhibitor, IL-17 inhibitor, or IL-23 inhibitor) for long-term control 1
3. Consider combination therapy for enhanced efficacy:
   • Acitretin + cyclosporine
   • Methotrexate + TNF blocker 4, 1

Important Considerations and Pitfalls

• Avoid systemic corticosteroids as they can trigger or worsen erythrodermic psoriasis upon withdrawal 6, 7

• Carefully monitor for secondary infections throughout treatment, as the compromised skin barrier increases infection risk 2, 3

• Contraindications to specific therapies:

  • Methotrexate: hepatic/renal disease, pregnancy
  • Acitretin: women of childbearing potential (teratogenic effects last up to 2 years)
  • Cyclosporine: severe renal disease, uncontrolled hypertension

• Drug interactions that influence cyclosporine levels should be carefully monitored

Monitoring During Treatment

• Regular assessment of vital signs and skin improvement
• Laboratory monitoring based on chosen systemic therapy
• Ongoing surveillance for secondary infections
• Evaluation of renal function, especially with cyclosporine therapy

The American Academy of Dermatology guidelines emphasize that treatment should be dictated by disease severity and patient comorbidities, with cyclosporine and infliximab being the most rapidly acting agents for this potentially life-threatening condition 1, 5.