What are the treatment options for pustular psoriasis on the finger in an outpatient setting?

Outpatient Treatment Options for Pustular Psoriasis on the Finger

For pustular psoriasis on the finger, the recommended first-line treatment is a combination of topical vitamin D analogues with potent class II or III topical corticosteroids. 1

First-Line Topical Therapies

• Combination therapy with vitamin D analogues and topical corticosteroids is recommended as the most effective approach for localized pustular psoriasis 1

  • Apply vitamin D analogues (calcipotriene) in the evening and high-potency topical corticosteroids in the morning 1
  • Alternatively, use vitamin D analogues twice daily on weekdays and high-potency topical corticosteroids twice daily on weekends for maintenance 1

• Fixed combination products containing calcipotriol and corticosteroids are particularly effective and convenient for finger lesions 1

• Tazarotene 0.1% cream or gel can be used for 8-12 weeks, particularly effective when combined with medium or high-potency topical corticosteroids 1

  • This combination increases efficacy while reducing local adverse events 1

Important Precautions

• Avoid simultaneous use of salicylic acid with calcipotriene as the acidic pH will inactivate calcipotriene and reduce its effectiveness 1

• Monitor for local adverse reactions with topical corticosteroids, including burning, itching, irritation, dryness, and skin atrophy 2

• Be cautious with high-potency corticosteroids in finger web spaces and nail folds due to increased absorption in these areas 3

• Avoid systemic corticosteroids as they can exacerbate psoriasis or provoke the pustular form of the disease upon discontinuation 4, 2

Second-Line Options

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are recommended for nail fold involvement as they don't cause skin atrophy 3

• Tazarotene 0.1% cream under occlusion has shown significant improvement in nail psoriasis with pustular involvement 1

• Acitretin is particularly effective for pustular psoriasis, with response seen as early as 3 weeks and improvement reported in 84% of patients 4, 5

For More Resistant Cases

• Methotrexate is effective in 76.2% of pustular psoriasis cases and is especially useful for acute generalized pustular psoriasis 1, 5

• Biologics (particularly TNF inhibitors and IL-17 inhibitors) should be considered for severe or treatment-resistant cases, especially with concurrent psoriatic arthritis 6

• Ustekinumab at 90mg dose has shown 67% clearance rate in patients with palmoplantar pustular psoriasis 6

Treatment Algorithm

1. Start with combination therapy: Vitamin D analogue + potent topical corticosteroid for 4-8 weeks 1
2. If inadequate response: Add tazarotene or switch to fixed combination product 1
3. For persistent cases: Consider acitretin (if no contraindications like pregnancy) 4, 5
4. For severe or refractory cases: Consider methotrexate or biologics 1, 6

Common Pitfalls to Avoid

• Prolonged use of high-potency corticosteroids can lead to skin atrophy, especially in finger web spaces 3, 2
• Abrupt discontinuation of corticosteroids may trigger disease flares or exacerbation 4, 2
• Failing to differentiate between pustular psoriasis and other pustular conditions like bacterial or fungal infections 3
• Using phototherapy alone for pustular forms, which may exacerbate the condition in some cases 7