What is the recommended treatment for a guttate psoriasis flare?

Treatment of Guttate Psoriasis Flares

For guttate psoriasis flares, the recommended first-line treatment includes low concentrations of topical coal tar and dithranol, with ultraviolet B (UVB) phototherapy being especially helpful for widespread lesions. 1, 2

First-Line Treatment Options

• Guttate psoriasis is generally a self-limiting condition, but active treatment may be necessary for symptom relief and to prevent progression to chronic plaque psoriasis 1, 2
• Low concentrations of topical coal tar (starting with 0.5-1.0% crude coal tar in petroleum jelly) should be used as erupting guttate psoriasis is less tolerant of topical treatments 1
• Low concentrations of dithranol (0.1-0.25%) can be used, with the short contact method (15-45 minutes daily) being particularly beneficial 1
• Ultraviolet B (UVB) phototherapy has the most robust evidence for efficacy in treating guttate psoriasis and is especially helpful for widespread lesions 1, 2, 3

Streptococcal Infection Management

• Investigate for streptococcal infection, as a significant proportion of guttate psoriasis cases have evidence of preceding streptococcal infection 1, 4
• Treat persistent streptococcal infection with phenoxymethyl penicillin or erythromycin 1, 4
• Consider referral to an otolaryngologist for tonsillectomy in cases of repeated guttate psoriasis attacks following documented episodes of tonsillitis 1

Second-Line Treatment Options

• Topical corticosteroids alone or in combination with other agents (vitamin D analogues) can be effective for mild cases 3, 4
• When using topical corticosteroids, follow these guidelines:
  • Regular clinical review is essential 1
  • No unsupervised repeat prescriptions 1
  • No more than 100g of a moderately potent preparation should be applied monthly 1
  • Include periods each year when alternative treatments are used 1
  • Potent or very potent preparations should only be used under dermatological supervision 1

Treatment Algorithm for Moderate-to-Severe Cases

• First-line: Topical corticosteroids and calcipotriol cream, combined with phototherapy (UVB) 3, 4
• Second-line: Traditional immunosuppressants such as methotrexate or cyclosporine for cases not responding to topical therapy and phototherapy 3, 4
• Third-line: Biologics for severe and refractory cases 4, 5

Important Considerations and Pitfalls

• Commercial sunbeds (emitting UVA) are rarely effective for psoriasis and may cause significant side effects; their use is not recommended 1, 2
• Avoid systemic corticosteroids as they can cause disease flare during tapering 2, 6
• If one topical treatment is ineffective, try an alternative before considering more aggressive management, as patients may respond differently to various agents 1
• Phototherapy should be supervised by adequately trained personnel with regular equipment calibration 1, 2

Treatment Monitoring

• Regular clinical review is essential for all patients on treatment 1
• Monitor for treatment response and adjust therapy accordingly 1
• Be aware that up to 40-50% of guttate psoriasis cases may persist and progress to chronic plaque psoriasis, necessitating long-term management strategies 4