What are the treatment options for pustular psoriasis in females of reproductive age?

Treatment of Pustular Psoriasis in Females of Reproductive Age

For women of reproductive age with pustular psoriasis, topical corticosteroids and narrowband UVB phototherapy are the safest first-line options, as all commonly used systemic agents are absolutely contraindicated in pregnancy and require strict contraception for extended periods. 1

Critical Contraception Requirements

All systemic agents used for pustular psoriasis are absolutely contraindicated in pregnancy and require mandatory contraception counseling before initiation. 1

Acitretin-Specific Requirements (Most Restrictive)

• Contraindicated for at least 3 years after discontinuation due to prolonged teratogenic potential 2
• Requires two negative pregnancy tests before starting (screening test, then confirmation during first 5 days of menstrual period) 2
• Monthly pregnancy testing during treatment, then every 3 months for 3 years after stopping 2
• Absolute prohibition of alcohol consumption during treatment and for 2 months after cessation (alcohol converts acitretin to etretinate, which has significantly longer half-life) 2
• Must use two effective forms of contraception simultaneously for 1 month before, during, and for 3 years after treatment 2

Other Systemic Agents

• Methotrexate: Contraindicated in pregnancy and breastfeeding; requires contraception for both men and women 1
• Cyclosporine: Requires contraception; contraindicated with abnormal renal function or uncontrolled hypertension 1
• PUVA: Contraindicated in pregnancy or wish to conceive 1

Treatment Algorithm by Disease Severity

Localized Pustular Psoriasis (Palmoplantar)

First-Line:

• Moderately potent topical corticosteroids (grade III) for symptom relief 3, 4
• Topical coal tar and dithranol may provide additional benefit 3

Second-Line (if topical therapy fails):

• Narrowband UVB phototherapy (safe in pregnancy) 5, 6
• PUVA if not pregnant or planning pregnancy within treatment period 3

Important Caveat: TNF antagonists (infliximab, etanercept, adalimumab) should be avoided in chronic palmoplantar pustulosis as they may exacerbate the condition 3

Generalized Pustular Psoriasis (GPP)

Immediate Management:

• Hospital admission usually required for initial management 3, 4
• Avoid systemic corticosteroids - they can precipitate disease exacerbation upon discontinuation and trigger erythrodermic or very unstable psoriasis 3, 4

For Non-Pregnant Patients with Reliable Contraception:

First-Line Systemic Options:

• Acitretin 0.1-1 mg/kg/day: Particularly effective for pustular psoriasis with response as early as 3 weeks; 84% improvement rate 3, 4, 2

  • Not immunosuppressive, making it advantageous 4
  • Remember the 3-year contraception requirement and alcohol prohibition 2

• Infliximab 5 mg/kg (weeks 0,2,6, then every 8 weeks): Demonstrates rapid and often complete disease clearance in severe GPP 3

  • May require dose intensification to 10 mg/kg or more frequent intervals (every 4 weeks) 3
  • Can be combined with methotrexate for augmented efficacy 3

Second-Line Options:

• Cyclosporine 2.5 mg/kg/day (divided twice daily): Initial dose with increases of 0.5 mg/kg/day every 2 weeks to maximum 4 mg/kg/day 1, 7

  • Response time approximately 3 weeks 1
  • Requires blood pressure and serum creatinine monitoring 1, 7

• Methotrexate: Especially useful in acute generalized pustular psoriasis 1

  • Response time approximately 2 weeks 1
  • Requires full blood count, liver function tests, serum creatinine monitoring 1

Combination Therapy:

• Acitretin combined with narrowband UVB shows synergistic effects 3, 4
• Extreme caution required as toxicity is at least additive 1, 3, 4

For Pregnant Patients:

• Narrowband UVB phototherapy is the safest systemic option 5, 6
• Topical corticosteroids under occlusion 5
• Recent case report shows secukinumab may be safe during pregnancy, though evidence is extremely limited 8

Monitoring Requirements

All Systemic Treatments Require:

• Pretreatment assessment including history, examination, full blood count, liver function tests, serum creatinine 1
• Regular ongoing monitoring with blood tests, liver function tests, and serum creatinine depending on agent used 3, 4, 9

Agent-Specific Monitoring:

• Acitretin: Liver function tests and fasting serum lipids 1
• Cyclosporine: Blood pressure and serum creatinine at each visit 1, 7
• Methotrexate: Full blood count and liver function tests regularly 1
• PUVA: Eye examination, UV eye protection, genital shielding 1

Critical Pitfalls to Avoid

1. Never use systemic corticosteroids as primary therapy - they precipitate disease flares upon discontinuation and can trigger erythrodermic or generalized pustular psoriasis 3, 4

   • Only consider in rare specific conditions: persistent uncontrollable erythroderma causing metabolic complications, von Zumbusch type GPP when other drugs contraindicated, or hyperacute psoriatic polyarthritis threatening irreversible joint damage 4

2. Do not prescribe acitretin without ensuring patient understands 3-year contraception requirement and alcohol prohibition 2

3. Avoid TNF antagonists for palmoplantar pustular psoriasis - they may worsen the condition 3

4. Do not abruptly discontinue steroids if patient is experiencing a flare - this worsens the condition 3

5. Certain medications worsen pustular psoriasis: lithium, chloroquine, mepacrine cause severe deterioration; beta-blockers and NSAIDs may worsen disease 9

Special Considerations for Reproductive-Age Women

• Pregnancy planning requires 3-year advance notice if using acitretin 2
• Most patients can transition to narrowband UVB if pregnancy desired 5, 6
• FDA pregnancy categories: TNF inhibitors (adalimumab, etanercept, infliximab) are category B; PUVA, cyclosporine are category C 1
• Relapse is common after stopping treatment - occurs in approximately 6-16 weeks for most patients 7