Is topical steroid allowed in the treatment of suspected pustular psoriasis?

Topical Steroids in Suspected Pustular Psoriasis

Topical corticosteroids should be avoided in suspected pustular psoriasis as they may induce or exacerbate generalized pustular psoriasis. 1

Rationale for Avoiding Topical Steroids in Pustular Psoriasis

• Topical corticosteroids, especially potent ones, can trigger generalized pustular psoriasis when used over extensive skin areas in patients with psoriasis 1
• Systemic absorption of topical steroids through damaged psoriatic skin can lead to a generalized pustular eruption 1
• Reduction of steroid doses (including topical) has been documented to induce generalized pustular psoriasis in psoriasis patients 2

Risks Associated with Topical Steroids in Pustular Psoriasis

• Potent topical steroids applied to large psoriatic areas can be absorbed systemically at clinically significant levels (equivalent to oral steroid tablets) 1
• Abrupt withdrawal of topical corticosteroids can cause rebound effects, potentially worsening pustular psoriasis 3
• The most common adverse effects of topical corticosteroids include skin atrophy, striae, folliculitis, telangiectasia, and purpura, which may further complicate pustular psoriasis management 3

Alternative Treatment Options for Pustular Psoriasis

• Acitretin is considered an effective treatment for pustular psoriasis 2
• For localized pustular psoriasis of palms and soles, moderate potency topical corticosteroids may provide symptomatic relief, but should be used with caution 3
• Narrowband UVB phototherapy can be an effective treatment option for pustular psoriasis, including during pregnancy when other treatments may be contraindicated 4
• Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are safer alternatives for sensitive areas like the face and intertriginous regions in psoriasis patients 3, 5

Special Considerations

• Generalized pustular psoriasis is a severe form that usually requires systemic therapy rather than topical treatments 3
• The differential diagnosis between pustular psoriasis and other pustular dermatoses (like acute generalized exanthematous pustulosis) is crucial, as treatment approaches differ significantly 2
• For mild localized pustular psoriasis, combination therapies that minimize steroid use are preferred, such as vitamin D analogs with limited corticosteroid application 5, 6

Management Algorithm for Suspected Pustular Psoriasis

1. Confirm diagnosis through clinical examination and biopsy if needed 2
2. Avoid topical corticosteroids, especially high-potency ones, over large areas 1
3. Consider systemic therapies (acitretin, methotrexate, cyclosporine) for generalized pustular psoriasis 3, 2
4. For localized pustular psoriasis, consider:
   • Vitamin D analogs (calcipotriene, calcitriol) 3
   • Topical calcineurin inhibitors for sensitive areas 3
   • Phototherapy (narrowband UVB) 4
5. If topical steroids must be used (e.g., for symptomatic relief in localized pustular psoriasis of palms/soles), use the lowest effective potency for the shortest duration possible under close medical supervision 3