What is the initial treatment for pustular psoriasis?

Initial Treatment for Pustular Psoriasis

Acitretin is the first-line therapy for generalized pustular psoriasis, particularly effective since it is not immunosuppressive and shows response as early as 3 weeks with improvement reported in 84% of patients. 1

Treatment Algorithm Based on Disease Severity

For Localized Pustular Psoriasis:

• First-line: Combination therapy with vitamin D analogues and topical corticosteroids (apply vitamin D analogues in the evening and high-potency topical corticosteroids in the morning) 2
• Fixed combination products containing calcipotriol and corticosteroids are particularly effective and convenient for localized lesions 2
• Tazarotene 0.1% cream or gel can be used for 8-12 weeks, particularly effective when combined with medium or high-potency topical corticosteroids 2

For Generalized Pustular Psoriasis:

• First-line: Acitretin at 0.1-1 mg/kg/day 1, 3
• Second-line options:
  • Methotrexate (effective in 76.2% of pustular psoriasis cases) 3, 2
  • Cyclosporine (initial dose of 2.5 mg/kg/day taken twice daily) 3
  • Biologics (particularly TNF inhibitors, IL-17 inhibitors, and IL-36 receptor antagonists) 3, 4

Important Considerations and Precautions

Avoid Systemic Corticosteroids

• Systemic corticosteroids should be avoided in pustular psoriasis due to the risk of disease exacerbation upon discontinuation 1, 3
• Systemic corticosteroids can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued 1, 3
• Limited exceptions for systemic corticosteroids include:
  • Persistent uncontrollable erythroderma causing metabolic complications
  • Generalized pustular psoriasis of the von Zumbusch type when other drugs are contraindicated
  • Hyperacute psoriatic polyarthritis threatening severe irreversible joint damage 1, 3

Combination Therapy

• Acitretin combined with narrowband UVB (NB-UVB) shows synergistic effects in pustular psoriasis 5, 1
• A case report noted successful treatment of refractory generalized pustular psoriasis in a 3-year-old boy with the addition of NB-UVB to acitretin therapy, allowing discontinuation of systemic steroids 5
• Approach combination therapy with caution as toxicity is at least additive 1, 3

Monitoring Requirements

• All systemic treatments require appropriate pretreatment assessment and ongoing monitoring 1, 3
• Regular blood tests, liver function tests, and serum creatinine monitoring are essential depending on the agent used 3
• For acitretin, monitor serum lipids and liver function testing at baseline and periodically 5

Emerging Therapies

• Spesolimab (IL-36 receptor antagonist) has shown promising results in treating severe generalized pustular psoriasis flares resistant to conventional treatments 6, 7
• Biologics targeting TNF-α, IL-12/23, IL-17, and IL-1β have shown effectiveness in treating generalized pustular psoriasis, with 61% showing complete response and 27% partial response 4

Special Considerations

• Pregnancy: All commonly used systemic agents (especially acitretin) are absolutely contraindicated in pregnancy, requiring strict contraception 1, 3
• Acitretin is contraindicated in pregnancy or women planning pregnancy within 2 years of stopping treatment 3
• For female patients of childbearing potential, consider isotretinoin when they have achieved stability with acitretin and wish to continue retinoid treatment 5