From the Guidelines
The treatment for an acute flare-up of guttate psoriasis should prioritize ultraviolet B radiation, as it is especially helpful, and low concentrations of tar and dithranol may be used, with investigations for streptococcal infection and treatment with phenoxymethyl penicillin or erythromycin if necessary. When managing guttate psoriasis, it's crucial to consider the potential for streptococcal infection, which may trigger the condition, as noted in the guidelines for management of patients with psoriasis 1. Key points to consider in treatment include:
- The use of ultraviolet B radiation, which is especially helpful for erupting guttate psoriasis
- The application of low concentrations of tar and dithranol, as higher concentrations may be too harsh
- Investigation for evidence of streptococcal infection and subsequent treatment with antibiotics such as phenoxymethyl penicillin or erythromycin if an infection is found
- Consideration for referral to an otolaryngologist for tonsillectomy in cases of repeated attacks of guttate psoriasis following documented episodes of tonsillitis, as suggested by the guidelines 1. Given the self-limiting nature of guttate psoriasis in most cases, treatment should focus on managing symptoms and addressing any underlying infections, with the goal of reducing morbidity and improving quality of life.
From the FDA Drug Label
Psoriasis: Methotrexate is indicated in the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by a biopsy and/or after dermatologic consultation The treatment for an acute flare-up of guttate psoriasis is not explicitly stated in the provided drug label. However, it is mentioned that methotrexate is used for the symptomatic control of severe, recalcitrant, disabling psoriasis.
- The label does not specify the treatment for an acute flare-up of guttate psoriasis.
- It is also mentioned that it is important to ensure that a psoriasis “flare” is not due to an undiagnosed concomitant disease affecting immune responses 2. The provided information does not directly answer the question about the treatment for an acute flare-up of guttate psoriasis.
From the Research
Treatment Options for Acute Flare-up of Guttate Psoriasis
The treatment for an acute flare-up of guttate psoriasis includes:
- Topical corticosteroids and calcipotriol cream, in combination with phototherapy, as first-line therapy 3, 4
- Supportive therapy with antibiotics if applicable 3
- Methotrexate or cyclosporine as second-line therapy 3
- Biologics as third-line treatment for severe and refractory cases 3
- Avoiding triggering and exacerbating factors 4
- Topical therapies such as vitamin D analogues, calcineurin inhibitors, anthralin, coal tar, and tazarotene 4
- Ultraviolet phototherapy, particularly narrowband ultraviolet B (UVB), as a first-line therapy for moderate-to-severe guttate psoriasis 3, 4
Evidence for Treatment Efficacy
The evidence for treatment efficacy is based on a systematic review of 75 studies, including 5 randomized controlled trials (RCTs) 3. However, the evidence is limited by high heterogeneity in study design and high risk of bias 3. Other studies have also reported limited evidence for the effectiveness of antistreptococcal interventions, including antibiotics and tonsillectomy, in the management of acute guttate and chronic plaque psoriasis 5, 6.
Need for Further Research
There is a need for further research, including RCTs, to provide higher quality evidence and create standardized treatment recommendations for guttate psoriasis 3, 7. Currently, there is no firm evidence to support or challenge current commonly used methods of management, and studies comparing standard treatment modalities are required to enable informed decisions on treatment choices to be made 7.