Guttate Psoriasis Treatment
For guttate psoriasis, start with low-concentration topical coal tar (0.5-1.0%) or dithranol (0.1-0.25%) combined with narrowband UVB phototherapy, as erupting guttate lesions are less tolerant of standard-strength topical treatments. 1, 2, 3
Key Clinical Context
Guttate psoriasis is self-limiting in most cases, with spontaneous resolution within 3-4 months, though up to 39-50% may progress to chronic plaque psoriasis. 1, 3, 4 This natural history should inform your treatment intensity—many patients require only supportive care unless symptoms are severe or cosmetically distressing. 4
First-Line Treatment Algorithm
Topical Therapy
- Start with LOW concentrations because erupting guttate psoriasis tolerates topical treatment poorly compared to chronic plaque psoriasis 1, 2
- Coal tar: Begin at 0.5-1.0% crude coal tar in petroleum jelly, increase every few days to maximum 10% as tolerated 1
- Dithranol (anthralin): Start at 0.1-0.25%, double concentration as response allows; use short-contact mode (15-45 minutes daily) to minimize irritation 1
- Alternative: Topical corticosteroids (moderately potent, grade III) combined with calcipotriol cream have strong evidence for efficacy 3, 4
Phototherapy (Preferred for Widespread Disease)
- Narrowband UVB is especially helpful and has the most robust evidence for guttate psoriasis 1, 2, 3
- More practical than topical therapy when treating numerous small scattered lesions 4
- Treatments given no more frequently than every 48 hours, typical course 8-10 weeks 1
- Must be supervised by adequately trained personnel with properly calibrated equipment 1
Streptococcal Infection Management
Investigate for streptococcal infection and treat any persistent infection with phenoxymethylpenicillin or erythromycin. 1
Critical caveat: While antibiotics treat underlying infection, evidence shows minimal connection between infection resolution and GP lesion remission—antibiotics are supportive therapy, not primary treatment. 3, 5 A Cochrane review found no improvement in psoriasis lesions with antibiotic treatment despite streptococcal eradication. 5
For recurrent guttate psoriasis after documented tonsillitis episodes, refer to otolaryngology for tonsillectomy consideration. 1
Second-Line Treatment (For Non-Responders)
If first-line therapy fails after 4-8 weeks:
- Methotrexate or cyclosporine for moderate-to-severe cases 3, 4
- These traditional immunosuppressants require dermatology supervision due to potential toxicity 1
Third-Line Treatment (Severe/Refractory Cases)
Biologics (ustekinumab, TNF inhibitors, IL-17 inhibitors) for severe, refractory guttate psoriasis unresponsive to phototherapy and systemic agents 2, 3, 4
Critical Pitfalls to Avoid
- Never use systemic corticosteroids—they cause disease flare during taper and can provoke pustular transformation 2, 6
- Do not use commercial sunbeds (UVA)—they are rarely effective and may cause significant side effects 1, 2
- Avoid high-potency topical corticosteroids initially—guttate lesions are more irritable than chronic plaques 1
- Do not prescribe antibiotics expecting direct lesion improvement—treat documented infection but don't rely on antibiotics as primary therapy 3, 5
Monitoring Requirements
- Regular clinical review when using topical corticosteroids 1
- No unsupervised repeat prescriptions 1
- Incorporate periods using alternative treatments throughout the year 1
- Most patients with guttate psoriasis can be managed by general practitioners; reserve dermatology referral for those requiring systemic agents 1
Evidence Quality Note
The evidence base for guttate psoriasis treatment is limited—only 5 randomized controlled trials exist, with most data from case series and retrospective studies. 3 A Cochrane review found no trials of standard treatments (topical corticosteroids, vitamin D analogues, phototherapy) specifically in guttate psoriasis populations. 7 The recommendations above synthesize guideline consensus with the best available evidence, recognizing this limitation. 1, 3, 4